HomeMy Public PortalAbout9837 GARIBALDI AVE_Plumbing__ 76A667-CE817 6-60 �
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APPLICATION FOR PLUMBING PERMIT
RETOCYG
DEPARTMENT F COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS
WILLIAM A. JENSEN. SUPT OF BUILDING
LOCALITY
FOR APPLICANT TO FILL IN CROSS ST.
NUMBER FIXTURE OR ITEM
OWNER
r WATER CLOSET MAIL
ADDRESS
BATH TUB
CITY TEL. NO.
SHOWER
CONTRACTOR
LAVATORY LAVATORY
SIN% ADDRESS
DISHWASHER CITY i TEL. NO.,,-Z, _.'Cj
CONTRACTOR'S STATE ❑
LAUNDRY TUB REGISTRATION NO. COUNTY ❑
r CLOTHES WASHER DISTRICT NO. GROUP ZONE I PR9C�ESSED� BY
WATER HEATER
GAS SYSTEM INDUSTRIAL
WASTE APPROVAL
INSPECTION RECORD
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f9 A ' o
P,
ul
a PER ITEM
OR
OR FIXTURE S APPROVALS DATE INSPECTOR'S SIGNATURE
PERMIT $ 2100 UNDER SLAB WORK
TOTAL FEE /cx— ROUGH PLUMBING
GAS PIPING
1 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
PLUMBING. HOT WATER HEATER
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR PLUMBING FIXTURES
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF GAS TEST
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY. UTILITY CO. NOTIFIED
SIGNATURE
OF PERMITTEE FINAL
Or 7VALIDATION ROBERT A. WOOD,
CC. Y.O. CASH SUPERVISING MECHANICAL ENG'R
Unuo-0 0 0i c 6 5 0 12.00
1
-- Ye-q,'IERS'COMPENSATION DECLARATIONAPPLICATION FOR PLUMBING .PER MIT `
I hereby, affirm that I have a certificate of consent to self In= 40-0044 DPW t/B7 n
764667A luf
sure,cr a certificate of Workers'Compensation Insurance,or a 817(REV. B/Bd)
certlfled copy thereof (Sec. 3800, Lab. C.)
Policy No. Compdny' COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
❑ Certlfled copy Is hereby furnished.
FOR APPLICANT TO F1 LL IN(PRINT CK2 TYPE) ILDItJG r
CerlFfled copy'Ic filed with the county building Inspection
department. NUMBER FIXTURE,OR ITEM FEE LOCALITIY
WATER CLOSET(TOILET)
Date Ap p I I ca n t NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS Si.
COMPENSATION INSURANCE SrtOY�Ek ER
(This salon need,not be complefod N the work Invohred by hAAIL
the permft Is for one hundred dollars ($IDD)or lean.) LAVATORY ADDRESS
I(fortify that In the performance of,the work for which this per- SINK
mit Is Issued, I shall not employ any person In any manner to
CITY TEL_
as to becom b to the Workers nsation L / DISFLWASHER
COI�CTOR
Dot Applicant CLOTHES WASHEk
NOT] O : If, after making this Certlficate of Ex- ADDRESS
emptlon,you should become subject to the Workers'Compen- SWIMMING POOL'RECEPTOR
satlon provisions of the Labor Code, you must forthwith comp,
CITY TEl
Pr Y LAWN SPkINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok' STATE LIC. '
ed. WATER HEATER L1Ca,SE NO. CLASS
LICENSED CONTRACTORS DECLARATIONGAS SYS,Em OUTLETS
-DKTRIq NO. BY
I hereby affirm that I am Iltensed under provisions of Chapter `�/1 7V1 8
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code, and my license Is In full force and ef- 5 LER SYSTEM FINAL VALIDATION >_
fect. DA O
Llcense Number Llc. Class U
FINAL Q
Contractor Date BY 0
H
1 am exempt under Sec. LU
W
B.aP.C. for this reason Plan check fee z
Date' PLUMBING PERMIT ISSUING FEE$ Q
Signature TOTAL FEE
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Plan check applicant
I hereby affirm that I aryl exempt from the Contractor's License Name
Law for the following reason (Section 7031.5, Buslneu and
Professions Code): Address
1, as owner of the property, will do the work and the C]h' Tel. No.
structure-Is not Intended or offered forsaIa(Section 7044,
Business and Professions Code). Poo.CONSTRUCTION LENDING AGENCY ' ,
I hereby affirm that there Is a construction.Iending agency for
the performarSce of the work for which this permit Is lisued
(Sp-c. 3097, Clv;C.).
Lenders Name � e-, �1
Lender's;Address'.;" E
I cartify'that I hove read this application and state that the
above Information It correct. I agree to comply with all County ►-' , f y
ordinances and State laws regulating Plumbing, and hereby
outhoN representatives of s County to enter upon the f
a m Honed pro rty Inspection purposes
-I SEE REVERSE FOR EXPLANATORY LANGJJ E
Signature of Permittee e