HomeMy Public PortalAbout10765 FREER ST_Plumbing__ ION
WORKER'S I have
a certificate
of consent to 76A666DPW9/89 APPLICATION FOR PLUMBING PERMIT
76A667A
I hereby affirm that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified
copy thereof(Sec.3800 Lab.C.)
COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV.-
Policy No. Company
❑ Certified copy is hereby furnished
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspection ADDRESS v/
department. NUMBER FIXTURE OR ITEM Q FEE LOCALITY
Date Applicant WATER CLOSET - NEAREST
BATH TUB
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST
,
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed if the work.involved by the SHOWER MAP BOOK PAGE / PARCEL
permit is for one hundred dollars($100)or less.) OWNER. / S clan ✓I
I certify that inrthe performance of the work for which this permit LAVATORY
is issued, I shall not employ any person in any manner so as toMAIL
�/�•
become subject to the Workers'Compensation Laws. ADDRESS
SINK
f{ / DISWASHER CITY TEL N�S/� j
Date! Applicant - CLOTHES WASHER CONTRACTOR
NOTIC TO APPLICANT: If, after making this Certificate of
Exemption-,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR
provisions of the Labor Code, you must forthwith comply with such ADDRESS
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM [/
LICENSED CONTRACTORS DECLARATION --------------- CITY /� �v�� TEL NOS/�� }
I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER �J s a
(commencing with Section•7000) of Division 3 of the Business and STATEGAS SYSTEM OUTLETS LICENSE NO %?CZ�� CLASS
Professions Code,and my license is in full force and effect.
OUTLETS OVER DISTRICT NO. PROCESSED BY Q
S PER SYSTEM O G O
License Numb ` C•- Lic.Class
FINAL VALIDATION d
DATE
Contractor Date 6 ! (J)
/ Z�r❑ I am exempt under Sec. BY AL z
B.&P.0 for this reason
Date: Plan check fee
Signature , /, ��'
PLUMBING PERMIT ISSUING FEE$ �� ea
❑ TOTAL FEE C� -
Plan check applicant
SINGLE FAMILY ! Y_.(. s
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Law =017 _ {_u 25
for the following reason (Section 7031.5, Business and Professions Address --
Code): T��-�_
❑ City Tel No
1,as owner of the property,will do the work and the structure j t HIL 4 � m 4
is not intended or offered for sale(Section 7044, Business
and Professions Code) , i)�it
- -
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 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 .
prop
ert ecU n sposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Sign t e of Permittee Date
CITCE 817(REV.6/78) 1
APPLICATION FOR PLUMBING P RM IT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING 'C�� F r y
NUMBER FIXTURE OR ITEM ® FEE ADDRESS
- 7
LOCALITY 3`•a c-1`
• WATER CLOSET ppNEAREST _ (\p
BATH TUB
C OSS ST t� l
SHOWER OWNER IA.
MAIL n
LAVATORY ADDRESS C: 12
SINK CITY -11f) Q�1 TEL NO qqR O
DISHWASHER CONTRACTOR I n
CLOTHES WASHER ADDRESS
SWIMMING POOL RECEPTOR
CITY C TEL NO.
LAWN SPRINKLER SYSTEM STATE LIC
WATER HEATER LICENSE NO CLASS
GAS SYSTEM OUTLETS APPROVALS DATE INSPECTOR'S SIGNATURE
OUTLETS OVER UNDER SLAB WORK
5 PER SYSTEM ROUGH PLUMBING
GAS PIPING
0
GAS VENT
HOT WATER HEATER
PLUMBING FIXTURES
GAS TEST QA
Plan check fee UTILITYCO NOTIFIED g
PLUMBING PERMIT ISSUING FEE$
TOTAL FEE FINAL
Plan check applicant PLAN CHECK VALIDATION
Name
Address
City ;' K WSPECOCH
I HEREBY ACKNOWLEDGE THAT I HAVE READ HSA CA ON A T q'] /� A {� /1
THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY OR INANCES z 2 4 4.V A
AND STATE LAWS REGULATING PG PERMIT VALIDATION I
O O O O O g
1HEREBY CERTIFY THAT I AMP P RLY REGISTERED NO OR L CENSED AS
REOU IR ED BY LOS ANGELES COUNTY A D STATE OF CA OR I OR T AT I AM THE I� y Q
LEGAL OWNER OF,AND INTEND TO E IDE IN IAB VE DE (BED RESIDENTIAL L O O 1 O O
PROPERTY
O O O 1 Q O O U
SIGNATURE
OF PERMITTEE r '0126-79
O 1.2 6 s�7 n
DISTRICT NO PR CESSED BY L / 7
INDUSTRIAL /
WASTTEEE AAPPPPR/O/VAL