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76A667A ICE 8178)- 1 1/76
1 ` APPLICATION FOR PLUMBING PERMIT
c, Cg -q 75 BUILDING AND SAFETY DIVISION
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING (-f i/ ( vim'
NUMBER FIXTURE OR ITEM ® FEE ADDRESS ` / ( (/(tel
WATER CLOSET LOCALITY
NEAREST
BATH TUB J-
CROSS ST. `
SHOWER OWNER ill n Cramer-
LAVATORY MAIL
ADDRESS
SINK CITY TEL.NO
DISHWASHER CONTRACTOR �� , C l0-
CLOTHES WASHERADDRESS Y► L([��%Cod e,Ma(Jr/
'
SWIMMING POOL RECEPTOR
CITY m TIL.NO-Z5--A175
LAWN SPRINKLER SYSTEM
STATE LIC.
WATER HEATER LICENSE NO CLASS
GAS SYSTEM OUTLETS DISTRICT NO. GROUP00 NE PR EZEB.,YkuO
UTLETS OVER ?^�
5 PER SYSTEM INDUSTRIAL
WASTE APPROVAL
INSPECTION RECORD V
LIC
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Plan check fee
PLUMBING PERMIT ISSUING FEE$
TOTAL FEE
Plan check applicant
APPROVALS DATE INSPECTOR'S SIGNATURE
Name
UNDER SLAB WORK
Address ROUGH PLUMBING
City Tel.No. GAS PIPING
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE GAS VENT
THATTHE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES
AND STATE LAWS REGULATING PLUMBING. HOT WATER HEATER
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR LICENSED AS PLUMBING FIXTURES
REQUIRED BY LOS ANGELES COUNTY AND STATE OF CALIFORNIA OR THAT I AM THE GAS TEST -
LEGAL OWNER OF,AND IN END TO RESIDE INT ABOVE DESCRIBED RESID TIAL
PROPERTY. UTILITY CO.NOTIFIED
SIGNATURE
OF PERMITTEE FINAL
PLAN CHECK VALE ION CK. M. CASH PERMIT VALIDATION CK. M.O. CASH
is
iy
F WORKERS'COMPENSATION DECLARATION SDPW-„87 APPLICATION FOR PLUMBING PERMIT
` I hereby;affirm that I have b cerflficate of consent to self In- 766667A
sure,or a certificate of Workers'Compensation Insurance,or a CE 817(REV..B%86)
certified copy thereof (Sec. 3800, Lab. C. COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No._Company
Certified copy.is hereby furnished. IBUILDING
FOR APPLICANT TO FILL IN(PRINT OR TYPE)
Certified copy Is filed with the county building Inspection �41ZZESS "Ib - C,
department- ((/`cant/1C.L NUMBER FIXTURE OR ITEM 8 FEE LOCALITY
Date AppflWATFR C105ET(TOILET) NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE SHOWEROWNER CJILAf/
(This section need not be compleited If the work Involved by MAIL
the perritFt Is for one hundred dollars ($I00)or leas.) LAVATORY ADp{�� W q Ers l r
I certify that In the performance of the work for Which this per-
mit Is Issued, I shall not employ any person In any manner so MMI14CTyTEL NO. ,v
as to become sukl1act to the Workers' Compensation Laws. DISHWASFI CONTRACTOR
Z?ate r ApV11cont LV� QOTHESWASHER
ADDRESS
NOTICE ICANT: If, after mak ng this Certificate of Ex- SWIMMING POOL RECEPTORemptlon,you should becomq tublect to the Workers'Compen CIT
cation prgvWons of thb'labc Code; you must forthwith comp LAWN SPRINKLER SYSTEM
ly"with such provisions or this permit shall be deemed revok- STATE LIG
ed. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTR NO BY
I hereby trfflrm thpt I am licensed under provlsiont of Chaptef GAS SYSTEM OUTLETS
9.(commencing with Section 7000)of Division 3.of the Businees OUTLETS OVER
and Professlons Code, and my license Is in full force and ef- 5 PER SYSTEM FINAL1�4 q
VALI TION ¢}
fect. DATE O
License Number Llc. Class 0
FINALA k>, Q
Contractor Date BY O
1 am exempt under Sec- W
B.BP.C. for this reason Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$ 10 6 3 9 A
Signature TOTAL FEE # o o o 0 05
SINGLE FAMILY
V-IOME OWNER-BUILDER DECLARATION Pion check applicant J o o �a 5 0
1 hereby affirm that I am exempt from the Contractor's License Name
(_aw for the following reason (Section 7031.5, Business and o '0 0.2 a 5 0�
Professions Code): Address
09.09-88
I--I I, as owner of the property, will do the work and the city Tel. No.
structure Is not Intended or offered for sale(Se4t4on 7044,
Bislress dnd Professlons Code). ,
CONSTRUCTION LENDING AGENCY
Ihereby affirm that there Is a construction lending agency for
the performance of the work for which thls permit Is Issued
(Sec. 3097, 0v. C.}
Lender's Name
Lender's Address.
I certify that I have read this application and state thgt 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
abovo-mentioned property for Iropection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Sig ure of Permittee Da e