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\ . APPLICATION FOR PLUMBING PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER rf
BUILDING AND SAFETY DIVISION ADDRESS O /—
JOHN A. LAMBIE. COUNTY ENGINEER 6 C< l<
WILLIAM A. JENSEN. SUPT OF BUILDING
_ LOCALITY i+
FOR APPLICANT TO FILL IN NEAREST
CROSS ST.
NUMBER FIXTURE OR ITEM EACH FEE
OWNER
WATER CLOSET $1.25 OIL, MAIL
/ BATH TUB 1.25 ADDRESS
as/ CITY TEL. NO.
SHOWER 1.25 /
LAVATORY 1.25 CONTAACTO O/yf
SINE 1,25 ADDRESS
DISHWASHER 1.25 CITY r0 I iO& T TEL. NO.
LAUNDRY TUB 1.25 CONREGISTRATION NO. , �(!. COUNTY 0
CLOTHES WASHER 1.25 06DISTRICT NO. GROUP �Ory,E PRO Y
WATER HEATER 1.50 8 = I
1.50 INDUSTRIAL }
GAS SYSTEM WASTE APPROVAL
OUTLETS d
OUTLETS OVER 5 PER SYSTEM .00 INSPECTION RECORD V
CC
tO
U
W
d
N _
APPROVALS t/ DATE_ 1 NSPECTON'S,SICNATURE
PERMIT 5 2 OO UNDER SLAB WORK
ROUGH PLUMBING
TOTAL FEE
GAS PIPING
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ GR APPLICATION
AND STATE THAT THE ABOVE IE CORRECT AND AGREE E LATIN GAS VENT
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING HOT WATER HEATER
PLV MBING.
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR PLUMBING FIXTURES
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF.AND INTEND TO GAS TEST b
RESIDE IN.THE ABOVE DESCRIBED RESIDENTIAL PR ERT Y. UTILITY CO. NOTIFIED
SIGNATURE / 1 /J
OF PERMITTEE ' 14 FINAL I-
LIDATION ROBERT A. WOOD
cR. M.o. cnsN SUPERVISING MECHANICAL ENG'R
a°.3882 Am 5 5 D 15.00-
W r KERS'COMPENSATION DECLARATION APPLICATION
B,p� p V�®pll I[/11D PLUMBING
mp p ppplp Opp I��IOppBN
I heroGy,.aitir that I have a certificate of consent to self in- 20-0026 DPW 4190 i9 Ir IL '4iAY N FOR Y�IL tLI'MB N PERMIT
p
sure,or a certificate of Workers'Compensation Insurance,or a 76A667A
certified copy thereof (Sec. 3800, lab. C.) cIILJII'
Policy No. Company
COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Certified copy is hereby furnished.
FOR APPLICANT-TO FILL IN(PRINT OR TYPE) BUILDING
❑ Certified copy is filed with the county building inspection - ADDRESS ��JJ
FIXTURE OR ITEM EE ry
department NUMBER FXTR@ FLOCALITY
Date Applicant
WATER CLOSET(TOILET) T
CROSS ST. .S /(/ -5;7CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB
COMPENSATION INSURANCE SHOWER OWNER E'
(This section need not be completed if the work involved by MAIL Q
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS
I certify that in the performance of the work for which this per- SINK
mit is issued, I shall not employ any person in any manner so CITY �� L� @q6N404
as to beco esu lett to the Workers' C m ensation ws DISHWASHER 7J,
L/ CONTRACTOR
DoteDoIe14 Applicant CLOTHES WASHER s
NOTICE TO APPLICANT: If, after making t Certificate of Ex- ADDRESS
em lion,you should become subject to th Workers'Com en- SWIMMING POOL RECEPTOR
P Y P CITY TEL. NO.
lotion provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEMS
Iy with such provisions or this permit shall be deemed revok- STATE LIC.
ed. WATER HEATER LICENSE NO. CLASS GI
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS D a
9(commencing with Section 7000)of Division.3 of the Business OUTLETS OVER G LGL
and Professions Code, and my license is in full force and af- 5 PER SYSTEM FINAL VALIDATION
Lice. S Wj7 Cg/ HOSE BIB DATE n C
((OO f��l— >� >
License Number Lic. ClassCL
la O
9 �(% NAL FI
Contractor Date BY U
S
F—] O
am exempt under Sec. V
B.aP.C. for this reason Plan check fee H
Dote' PLUMBING PERMIT ISSUING FEE$ Z
Signature TOTAL FEE
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Plan check applicant - 5
1 hereby affirm that I am exempt from the Contractor's License Nome
Low for the following reason (Section 7031.5, Business and ACCT.:
Professions Code): Address 'ti•Ja"` ..J.: •:�
33034- ,r., ' 125.50
❑ I, as owner of the property, will do the work and the City Tel. No.
structure is not intended or offered for sole(Section 7044, • -U 1_.LTEMN.T�„
Business and Professions Code). TOTAL 125. 50
CONSTRUCTION LENDING AGENCY CHECK 125.50
1 hereby affirm that there is a construction lending agency for CHANGE
the performance of the work for which this permit is issued •00
(Sec. 3097, Civ. C.).
Lender's Name
0000-0001 2/ 8/96
Lender's Address -
4764 1 AM10:03
I certify that I hove read this application and state that the
above information is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of I is County to en er upon the
abo e- enfioned pro r nspection pure
2 SEE REVERSE FOR EXPLANATORY LANGUAGE
Sig
natur erm iftee D to