HomeMy Public PortalAbout5470 ENCINITA AVE_Plumbing__ 4
76A66677A •�
CE 817(REV 6/78)
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APPLICATION FOR PLUMBING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
ADDRESS / Q j��
NUMBER FIXTURE OR ITEM ® FEE
LOCALITY
WATER CLOSET �F' T
NEAREST n"
BATH TUB CROSS ST Y /
SHOWER OWNER //, 1/,EMA L
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LAVATORY ADDRESS / OKO
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SINK CITY f7�� �+ 7- TEL NOCg-,e—,?4/CF0
DISHWASHER CONTRACTOR /,,41-.WG COAJ.197—
CLOTHES WASHER ADDRESS
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SWIMMING POOL RECEPTOR
CITY &&tt/T P�1Z(` TEL NO >z3�3
LAWN SPRINKLER SYSTEM STATE ,c/ LIC
WATER HEATER LICENSE NO �3 ��/� CLASS
GAS SYSTEM OUTLETS APPROVALS DATE INSPECTOR S SIGNATURE
OUTLETS OVER UNDER SLAB WORK q e
5 PER SYSTEM ROUGH PLUMBING
GAS PIPING
GAS VENT u
QE
HOT WATER HEATER p®
PLUMBING FIXTURES 7 �D
�0
GAS TEST
Plan check fee UTILITYCO NOTIFIED
PLUMBING PERMIT ISSUING FEE$
TOTAL FEE FINAL
Plan check applicant — PLAN CHECK VALIDATION
Nameh
Address
City Tel No �22
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE _ Q 2 6 63 A
THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES
AND STATE LAWS REGULATING PLUMBING PERMIT VALIDATION
# o 0 0 o Q 5
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR LICENSED AS
REQUIRED BY LOS ANGELES COUNTY AND STATE OF CALIFORNIA OR THAT I AM THE O - 2200
LEGAL OWNER OF AND INTEND TO RESIDE IN THE ABOVE DESCRIBED RESIDENTIAL
PROPERTY
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SIGNATURE '
OF PERMITTEE 0208-79 2 0 8—79
DISTRICT fy0� PRO E ED BY V Y
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INDUSTRIAL
WASTE APPROVAL
WORKERS'COMPENSATION DECLARATION 20-0026 DPW 4/90 APPLICATION FOR PLUMBING PERMIT
I hereby, affirm that I have a certificate of consent to self in- 76A667A
syre,or a certificate of Workers'Compensation Insurance,or a
certified copy thereof (Sec. 3800, Lab. C.)
COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No. Company
E] Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING �
Certified copy is filed with the cou ty buildin i.spection ADDRESS t/
App NUMBER FIXTURE OR ITEM @ FEE
department. � LOCALITY
Date Applicant WATER CLOSET(TOILET) NEAREST '
CERTIFICATE OF EXEMPTION FROM WORKER BATH TUB CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER
(This section need not be completed if the work i volved by MAIL
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS
I certify that in the performance of the work for which this per- SINK CITY TEL. NO.
mit is issued, I shall not employ any person in any manner so
as to become subject to the Workers'Compensation Laws. DISHWASHER '
CONTRACTOR
Date Applicant CLOTHES WASHER
ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR
emption,you should become subject to the Workers'Compen- CITY TEL. NO.
sation provisions of the Labor rode, you must forthwith comp-. LAWN SPRINKLER SYSTEMS
ly with such provisions or this permit shall be deemed revok- STATE LIC.
ed. WATER HEATER LICENSE 1\10.5 1-2421)
LICENSED CONTRACTORS DECLARATION DISTRICT L40. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS Com',e -'
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
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and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINA �j �FA�I ATION
v
fect. HOSE BIB DATE V' _ ~�
'1•i��a_�
License Number 1 Lic. Classs M
� FINAL 0
ContractorDate) L BY
t.� r yr
J _ 3_i t HL
ElI am exempt under Sec. t_-Li_.i? ��3CR
B.&P.C. for this r anon Plan check fee ==HAN1GE F<<'I�
►. ". 6s7
Date: PLUMBING PERMIT ISSUING FEE$
Signatur TOTAL FEE �! IJ 1..i;
SINGLE FAY
HOME OWNER-BUILD DECLARATION Plan check applicant A1°i'��:{+
I hereby affirm that I am exempt from the Contractor's License Name
Law for the following reason (Section 7031.5, Business and
Professions Code): Address
I, as owner of the property, will do the work and the City Tel. No.
structure is not intended or offered for sale(Section 7044,
Business and Professions Code).
110-
CONSTRUCTION
CONSTRUCTION LENDING AGENCY.
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
I certify t at I have read this application and state that the ,
above inf rmation is correct. I agree to comply with all County
ordinanc and State laws regulating Plumbing, and hereby
out
representati f this County to enter upon the
above- ntiongd p for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee atel �