HomeMy Public PortalAbout10679 FREER ST_Plumbing__ DBS,17 f0-55 APPLICATION FOR PLUMBING PERMIT
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DIVISION OF BUILDING AND SAFETY
Department of County Engineer
County of Los Angeles B U I LD I NG /f 1T
.JOHN A. LAMBIE, COUNTY ENGINEER - ADDRESS G�
CASSATT D. GRIFFIN, SUPT OF BUILDING / f
MOMLOCALITY y _
FOR APPLICANT,-12 ILL• I NEAREST
Rosss r. G�1
OWNER DISTRICT NO. GROUP ZONE READY FOR INSPECTION
ADDRESS
MAIL
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INDUSTRIAL
TEL. NO. WASTE APPROVAL -
PLUMBERvGG�'<� !/ INSPECTION RECORD
ADDRESS
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CITY
CITY/}' Lfi"- f/ �`gTEL. NO.// !%•S!'S _ -
LICENS NOts '
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NUMBER TYPE OF FIXTURE OR ITEM FEE
WATER CLOSET (TOILET) @ $1.00 $
BATH TUB @ $1.00 -
SHOWER @ $1.00
LAVATORY (WASH BASIN) @ $1.00 -
KITCHEN SINK @ $1.00 _
DISHWASHER @ $1.00
LAUNDRY TUB OR TRAY @ $1.00
CLOTHES WASHER @ $1.00
WATER HEATER @ $1 00 �D
GAS SYSTEM @ $1.00 Qf✓
APPROVALS
DATE INSPECTOR'S SIGNATURE
• - UNDER SLAB WORK
PERMIT $ 00 ROUGH PLUMBING
- f GAS PIPING
TOTAL FEE C j(,)
GAS VENT
I D HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION HOT WATER HEATER
ANSTATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES -AND STATE LAWS REGULATING
PLUMBING. PLUMBING FIXTURES
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR GAS TEST
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT I,/'AM HE LEGAL OWNER OF THE ABOVE UTILITY CO.NOTIFIED
DESCRIBED RESIDENTIALPRI
//RRTY,
SOF PERMIT !�!/J �' "- �•�'
FINAL
JOHN A. LAMBIE. COUNTY ENGINEER VALIDATION,f'''. ROBERT A.WOOD, CHIEF PLBG. INSPECTOR '
CK. M.0. /CASH 1 '
WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self 76A667A
insure, or a certificate of Workers' Compensation Insurance, CE 81y(REV 10/81)
or a certified copy thereof (Sec 3800, Lab C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
Certified copy is hereby furnished
❑ FOR APPLICANT TO FILL IN PRINT OR TYPE BUILDING y�
Certified copy is filed with the county building inspec- ( ) ADDRESS d� ` �r �e 5'
Tion department NUMBER FIXTURE OR ITEM @ FEE LOCALITY �p '�
Date Applicant WATER CLOSET `y NEAREST ' /
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST
COMPENSATION INSURANCE HOWER OWNER ` 114`./C,
(This section need not be completed if the work involved by MAIL Y
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS �f e
I certify that in the performance of the work for which this
permit is issued, I shall not.employ any person in any manner SINK CITY TEL NO U 33
c
so as to become subject to the Workers Compensation Laws. DISHWASHER
- - •� CONTRACTOR
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT If, after making this Certificate of '
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY TEL NO
with comply with such provisions or this permit shall be STATE • LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 AGAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER >_
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL J �/� VALIDATIONCL
License Number Lic. Class 4. G l
v ByFIN�" 0
Contractor Date BY
❑ I am exempt under Sec LU
B 8P C. for this reason H
Date.
Plan check fee pop- z
PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE
SINGLE FAMILY
Plan'check applicant G+ S(f -R 0,7 Q 4 A
'
HOME OWNER-BUILDER DECLARATION Name
4-1C LIS 0 } 0
!0'0 0 0
1 hereby affirm that I am exempt from the Contractor's License --- ' '
Law for the following reason (Section 7031 5, Business and Address C' fie' 2'o�o 41 6 5'0
Professions Code): City r Tel, No.;10 •3J
I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section
7044, Business and Professions Code)
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 that I have read this application and state that the c ►
above information is correct I agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
auth rite representatives of this.County to enter'upon the
ab -mentioned property for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
V,gnatu of Permittee Date