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76A667 -CE#817 2-62
APPLICATION FOR PLUMBING PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS y� ,
WILLIAM A. JENSEN, SUPT OF BUILDING
LOCALITY
FOR APPLICANT TO FILL IN NEAREST
ROSS ST .
NUMBER FIXTURE OR ITEM EACH FEE
r OWNER
WATER CLOSET $1.25 2 J MAIL /
BATH TUB 1.25 f L ADDRESS
SHOWER 1 25CITY TEL. NO.
s
+Z LAVATORY 1.25 3-b CONTRACTOR
SINS 1.25 S- ADDRESS 1,?IS S
DISHWASHER 1.25 CITY j TE . NO. 73-7q
CONTRACTOR'S STATE
LAUNDRY TUB 1.25 REGISTRATION NO. C '3 Ci /339 `G COUNTY
CLOTHES WASHER 1.25 DISTR CT NO. GROUP ZONE PR SSED BY
WATER HEATER 1.50 2 sG C-t
GAS SYSTEM OUTLETS 1.50 INDUSTRIAL
WASTE APPROVAL
OUTLETS OVER 5 PER SYSTEM 30 b INSPECTION RECORD
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to
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D APPROVALS ATF! INSPECTOR'S SIGNATURE
PERMIT $ 2 00 UNDER SLAB WORK 'S/''
J� ROUGH PLUMBING''
TOTAL FEE J,5d✓ GAS PIPING L i'
I HEREBY ACKNOWLEDGE THAT I 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 HOT WATER HEATER
G.
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR PLUMBING FIXTURES
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF,AND INTEND TO GAS TEST
RESIDE IN,THE ABOVE DE HIED RESIDE IAL PROPERTY UTILITY CO. NOTIFIED -
LLOF
ATURE
MTEE I
! r
FINAL n
ALIDATION ROBERT A. WOOD
CK. M.O. CASH SUPERVISING MECHANICAL ENG'R
4
_,,r, ick'COMPENSATION DECLARATION 76A667A
I hr *�s;"affirm that I have a certificate of consent to self ce 817 (2-60) APPLICATION FOR PLUMBING PERMIT
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800, a ) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
Cerci ed cop is hereby furnis d. R APPLICANT TO FILL IN (PRINT OR TYPE) BUILD
C fled filed with e c nt buildi inspectio U ER FIXTURE OR ITEM • FEE ADDRESS
WATER CLOSET LOCALITY
Dat A icant NEAREST
v
CER IFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. LCX V'-,
COMPENSATION INSURANCE SHOWER OWNER
MAIL "IT
(This section need not be completed if the work involved LAVATORY ADDRESS % G- .
by the permit is for one hundred dollars ($100) or less.) SINKNO. (r'� O
(,
I certify that in the performance of the work for'which this DISHWASHER CIT � TEL.
permit is issued, I shall not employ any person in any manner CONTRACT88
so as to become subject to the Workers' Compensation Laws. CLOTHES WASHER o
ADDRESS
Date Applicant SWIMMING POOL RECEPTOR 2Q ���7� IU
NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL.NO.t, 2 � CL
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM Z
STATE //�� LIC. ��d
Compensation pith loris of the Labor Code, you must forth WATER HEATER LICENSE.NO.`or C S
with comply with such provisions or this permit shall be
`deemed revoked. GAS SYSTEM OUTLETS DISTRICT NO.. R SSED
LICENSED CONTRACTORS DECLARATIONOUTLETS OVER G �d
` I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
Il 9 (commencing with Section 7000) of Division 3 of the Busi- FINAL r y�� VALIDATION
ness and Professions Code, and my license is in full force and DATE %1
effect.
FINALC
License Number— Lia Clas FI
IA�x
iContractor Date Plan check fee
I am exempt from the licensing requirements as I am a
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$
acting in my professional capacity (Section 7051, Bus- 00
iness and Professions Code). CX--:)TOTAL FEE l�
Lic.or Reg.No. Date Plan check applicant
HOME OWNER-BUILDER DECLARATION Name
I he affirm that I am exempt from the Contractor's Address
License Law for the following reason (Section,7031.5, Busi- City Tel.No.
ness and Professions Code):
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project 1 4 8 0,0 A
(Section 7044, Business and Professions Code).
0 0 0 0 0°5
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency w 2 0 0 1 0.00
for the performance of the work for which this permit is ?� ,�+
issued(Sec. 3097,Civ.C.). tl�.uw, w s{ % of�y 0 0 0 1 000'
Lender's Name 5 of{� F!I?.
Lender's Address 1
I certify that I have read this application and state th't the %���
above inform n is cor t.I agree to comply with all ounty SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances nd State laws Le
Plumbing, an hereb
a epresentatives of is County t ente u n e ,
above-me ion o rty for' spect' nlWole .
Signature of Permittee Date