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HomeMy Public PortalAbout5030 FIESTA AVE_Plumbing__ t 76A667 CE811 3-59 APPLICATION FOR PLUMBING PERMIT COUNTY OF LOS ANGELES DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DMSION BUILDING JOHN A LAMBIE County En meer ADDRESS CASSATT D GRIFFIN Supt of Buildmg LOCALTfY FOR APPLICANT TO FILL IN NEAREST CROSS ST d-s eL NUMBER FIXTURE OR ITEM OWNER �'• WATER CLOSET MAIL BATH TUB ADDRESS CITY TEL NO SHOWER / LAVATORY CONTRACTOR Z 6 SINK ADDRESS DISHWASHER CITY Wpvviaylll, NO CONTRACTOR S STATE LAUNDRY TUB REGISTRATION NO W COUNTY 171 CLOTHES WASHER DISTRICT NO aQL ZONE PROCESSED BY WATER HEATER GAS SYSTEM INDUSTRIAL WASTE APPROVAL //INSPECTION RECORD / o a g1 tm PER ITEM AZ- /J OR FIXTURE $ J 0 ,0 APPROVALS / DATE INSPECTOR S SIGNATURE PERMIT $ 2 00 UNDER SLAB WORK FEE ROUGH PLUMBING ` Q�] t.- TOTAL ti _ �9 GAS PIPING ` � w I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION >, AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY GAS VENT WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING HOT WATER HEATER PLUMBING I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR PLUMBING FIXTURES LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF GAS TEST / CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERi UTILITY CO NOTIFIED SIGNATURE OF P ERM I T TE FINAL OFVALIDATION ROBERT A WOOD C6 Y O CASH SUPERVISING MECHANICAL.ENG R L,Cooa8B O iliA( 17 5 A 1300 M WOCOMPENSATION DECLARATION APPLICATION FOR PLUMBING G PERMIT •` .I'-heree by affirmrm that I have a certificate of consent to self 20-0026 DPW 6/87 insure, or a certificate of Workers' Compensation Insurance, 76A667A br a certifibd copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Potcy No. Company Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy is filed with the county building inspec- ADDRESS tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY T. TZ Date Applicant WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE SHOWER OWNER VIiIN' (This section need not be completed if the work Involved by Z MAIL the permit is for one hundred dollars ($100)or less.) / LAVATORY ADDRESS I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in any manner SINK CITY TEL. N ✓D so as to become subject to the Workers'Compensation Laws. DISHWASHER CONTRACTOR Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR Exemption, you should become subject to the Workers' CITY TEL. NO. Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE LIC. deemed revoked. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER !/Q and Professions Code,and my license is in full force and effect. 5 PER SYSTEM W FINAL VALIDATION DATE License Number Lic. Class / ©� 0. FINAL Contractor Date BY ❑ I am exempt under Sec. V BAP.C. for this reason Plan check fee D tai Date: PLUMBING PERMIT ISSUING FEE$ !� Signature TOTAL FEE a� b Plan check applicant SINGLE FAMILY HOME OWNER-BUILDER DECLARATION dame +'a •_` I hereby affirm that I am exempt from the Contractor's License Address Law for the following reason (Section 7031.5, Business and _ !'i='• =• Pro ssions Code): City Tel. No. /1kI, as owner of the property, will do the work and the _ _.r. ;^f..�s structure is not intended or offered for sale (Section ® '; ., ?, :,? 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY •''��''?= z" 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.). Y ,;_r _.I..?.:, N. .,_. Lender's Name "iMv-w hY;t; Lender's Address I certify that I have 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 this County to enter upon the above-mentioned plroperty for inspection purposes. / SEE REVERSE FOR EXPLANATORY LANGUAGE Signatur ofrmitt� Date