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HomeMy Public PortalAbout9854 ESTRELLA AVE_Plumbing__ ' ]fi Afi B]C ICE'81713I -9/]fi � • l' I APPLICATION FOR PLUMBING PERMIT {� BUILDING AND SAFETY DIVISION FOR APPLICANT TO FILL IN (PRINT OR TYPE, BUILDING 9� ADORE ;5D leST,Q EL 1-.q AvA. NUMBER FIXTURE OR ITEM C FEE WATER CLOSET 3 �--� LOCALITY V /�-�./� L� / L BATH TUB NEAREST CROSS ST. SHOWER OWNER L G e LAVATORY 2 O jJ MAIL ADDRESS �y — SINK CITY^// LE `jT TEL. NO.,/7,e7. -776 DISHWASHER CONTRACTOR — CLOTHES WASHER ADDRESS $WIMAIING POOL RECEPTOR CITY TEL. NO. _ LAWN SPRINKLER SYSTEM STATE LIC I _ WATER HEATER LICENSE NO. -- CLASS DISTRICT NO. I GROUP ZONE ROC ED BY GAS SYSTEM OUTLETS DI l�Jj N E OUTLETS OVER 5 PER SYSTEM INDUSTRIAL ILIw WASTE APPROVAL w INSPECTION RECORD Z Plan check fee PLUMBING PERMIT ISSUING FEE $ -� TOTAL FEE Plan check applicant Name APP ;LS DATE Ins PED,]OR's SIGNATURE UNDER WORK 1: 7 Address ROUGH PLUMBING City Tel. No. GAS PIPING 7`•�i Mfr �� I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION GAS VENT AND STATE THAT THE ABOVE IS CORRECT AND AGR TD COMPLY WITH ALL COUNTY ORDINANCES ANO STATE LA flE EATING HOT WATER HEATER PLUMBING. I HEREBY CER T(FT THAT 1 A P P LY GIST R AND/OR PLUMBING FIXTURES LICENSEDAS REQUIRED BY LO /A GE S CO NTY N STATE OF GAS TEST CALIFORNIO A R THAT I AM TH A OWN NO INTEND TO RESIDE IN THE ABOVE DESC O NY F PRO ERTT, UTILITY CO. NOTIFIED SIGNATURE / OF PERMITTEE FINAL PLAN CHECK VALIDATION CK. M.O. cA 'R PERMIT VALIDATION cK. .O. CASH / -- – 1 OfiJAN 3 5 0 2 2.5 0 a WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING ®ERMIg I hereby affirm that t have a certificate of consent to self 200026 DPW 6/87 insure, or a certificate of Workers' Compensation Insurance, 76A667A or a certified copy thereof (Sec. 3800,, Lab. C.) �, .� COUNTY OF LOS ANGELES DEPT:OF PUBLIC WORKS Policy NoL7.�,aM :—k mpony :�iL�U'lYac- 1k ,. Certified copy is hereby furnished. t�I FOR APPLICANT TO FILL IN(PRINT OR TYPE) AD ILDING 17CI Certified copy is filed with the county building inspec- ADDRESSDRESS J 57L tion department. lam. h� NUMBER FIXTURE OR ITEM @ FEE LOCALITY [ i10, f' Date _ ry Applicant,1,` �e ^e� WATER CLOSET NEARESTvta I CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. Ni 11) COMPENSATION INSURANCE OWNER (This section need not be completed if the work involved by SHOWER ' the permit is for one hundred dollars ($100)or less.) LAVATORY MAII','x ADDRESS\ I certify that in the performance of the work for which this �- permit is issued, I shall not employ any person in any manner SINK CITY ti, \ o f TEL. NO. so as to become.subject to the Workers'Compensation Laws. DISHWASHER Vim. O& CONTRALTO } a Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR c7lJs Exemption, you should become subject to the Workers' _ Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY TEL. NO, with comply with such provisions or this permit shall be STATE LIC. (+ deemed revoked. WATER HEATER ' LICENSE NO. _ CLASS l_. LICENSED CONTRACTORS DECLARATION D)STRICT NO. PROC SSED BY I hereby off IrIn that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS �• O (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER vFINAL and Professions Code,and m >Y .license is in full force and effect. 5 PER SYSTEM �J VALIDATION O !l f� �&,>QU DATE o License Number-1�_[00) Lic. ClassL . U L, FINA Contractor BY Q, ❑ I am exempt under Sec. W B.BP.C. for this reason D N' Plan check fee Date: z ' PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE p Plan check applicant SINGLE FAMILY =' HOME OWNER-BUILDER DECLARATION Name - a I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Address Professions Code): City Tel. No. ``i.7 ��°•-� ❑ 1, as owner of the property, will do the work and the - j HEMS structure is not intended or offered for sale (Section `lit fSD iL 16 °c 7044, Business and Professions Code), CONSTRUCTION LENDING AGENCY CLOCK 115,'dj I hereby affirm that there is a construction lending agency for o the performance of the work for which this permit is issued Lafutf`nSE fl { . (Sec. 3097, Civ. C.). Lender's Name - 0]12C_—Fi 4/19/39 Lender's Address ;a °�7 1 certify that I have read this application and state that the © vu_, 1 AN T1°J1r above information is correct. I agree to comply with all County ordinances and State lows regulating Plumbing, and hereby authorize representatives of this County to enter upon the r above-mention roperty for inspection purposes: SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee