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78 A e97—CE 817 9/88 Ci}ter Of Temple City
APPLICATION FOR PLUMBING PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGMEEE7CRO683T.
BUILDING AND SAFETY DIVISION . b0 Gid1e Rd.
JOHN A. LAMBIE, COUNTY ENGINEER COLEMAN W. JENKINS. SUPT. OF BUILDING Tem le Cit .
FOR APPLICANT TO FILL IN R O TYPE Temple Cit Blvd.
NUMBER FIXTURE. OR ITEM EACH FF-11
HATER CLOSET 1.50 OAxxl H. Kavanagh
BATH TUB1.50 �as 9609 Gid1e7 Rd.
SHOWER 1.50 CITY Temple Cit7 Tlu- No. 448-847 9
LAVATORY 1.50 CO TRACTM J & D Plumbing CO.
SINk 1.50 ADDIEN 414 So. San Gabriel Blv
DISHWA3HHR 1.50 =T S'an Gabriel na- XO• At. 70579
CLOTHES WASHER 1.50 •TATE o LIC
LITEMS[ NO. 8 b CLASS b
Swnaf liG POOL RECEPTOR 1.50 DISTRICT N ORTIP ZONE P BY
LAWN SPRINKLER SYSTEM 2.00 V / S
7
WATER HEATER 1.50 umuffTII� �o
WPJM APPROVAL
GAB SYSTEM OUTLETS 1.50 Dt5PZ=0X KZCORD
W
OUTLETS OVER
5 PER SYSTEM 30 =
Turn P1bg for ieWEr O
Plan check fee E5% of above. See reverse.
PLUMBING PERMIT ISSUING FEE f 2 00
TOTAL FEE
APPROVALS DATE IN/PEGTOR'//IONATU RE
Plan check applicant UNDER SLAB WORK
Name ROUGH PLUMBING
Address GAS PIPING
GAS VENT
IS City Tel. No. HOT WATER HEATER
1 HERESY ACKNOW L[DO[ THAT I HAV[ READ THIS APPLICATION
AND /TAT[ THAT THE ADOVE 1/ COMW-Cr AND AOREI TO COMPLY PLUMBING FIXTURES
\►1rH ALL COUNTY ORDINANCZI AND STATE uw/ RE.uuTIN/ GAS TEST -
FLU Mo
ALM
CERTIFY THAT I AM PROPERLY REOISTERI D AND/OR UTILITY CO.NOTIFIED
LICXN= AS REQUIRED ■Y LOf AN I" COUNTY AND /TAT[ OF
AUFORNIA OR THAT 1 AM THE LE OWNER OF,AND INTtND TO
RE/IDE IH•THE AIOYE DEKR7/ED I L PROPERTY. FINAL
>f
SIGNATURE JACK R. ALLEN, 8U RVISINa MECHANICAL R.
OF PER ITT[
PERWr VALIDATION CK. M.O. CASH
PLAN CHEM V ATION CK. CASK--
_ [V,�2 2 0 ? tlCt 1 �. 5 Q 3.5 0 v
RKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
affirm that Dave a certificate of consent to self 764667A
�tinsSv , or a certificate of Worker' Compensation Insurance, CE 817(REV. 10/61) u
dor 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 (//J ,r p j1 L/ 7Q
Certified copy Is filed with the county building Inspec- ADDRESS –G
tlon department. NUMBER FIXTURE OR REM O FEE LOCALITY
Date Appllgant WATER CLOSET NEARESTD
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST, � �� /T� F��V
COMPENSATION INSURANCE SHOWER OWNER, U/,17;i E a r�Svk
(This section need not be completed H the woric Involved by
MAL
that'permit Is for one hundred dollars (=100)or less.) LAVATORY 06 ADpRM
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 �!� �� �1/ TEL
so as to ome subject to the Workers Compensation Laws. DISHWASHER
y/ OONTRA.CTOR 44., r '.'. La Poe
Date I Applicant QOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certlflcat f ADDRESS!Bd �aXJT d/ prV
Exemption, you should become subject to the Wo rs' SWI.MUNG POOL TOR �yC, /f� u� q
Compensation provisions of the Labor Code, you must rth- LAWN SPRINKLER SYSTEM `���' ml w TEL
No.W^ ! O,;
with comply with such provlslons.or this permit shall be STATE UC_ p
deemed revoked. WATER HEATERCLJ
LICENSED CONTRACTORS DECLARATION DtSTRKT NO BY
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
and Profeulons Code,and my license Is In full force and effect. S PER SYSTEM FDINAL#
ATE
License Number Llc. Class 0Q:
F I NAL C.7.
Contractor Date BY W
❑ I am exempt under Sec. 0
U
B.BP.C_ for this reason
Plan check fee
Date: C/)
PLUMBING PERMIT ISSUING FEE$ Z
Signature —`
TOTAL FEE
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License 2 6 5 a 7 A
Address
Law for the following reason (Section 7031.5, Business and # 0 0 0 0 0 5
Professions Code): City Tel. No.
❑ I, as owner of the property, will do the work and the ( 4 c 2 &5 0
structure Is not Intended or offered for sale (Sectlon 1
7044, Buslnesa and Professions Code). , o o,0 2 a 5 0 5
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for 0219-87
the performance of the work for which this permit Is Issued
(Set. 3097, Clv. C.).
Lende+'s Name
Lender's Address
I certify that I have read this application and state that the , \
above Informatlon.ls correct. I agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
authorize reprelentatives of this County to enter upon the \
above-mentioned property for Inspection purposes.
/ SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Dat