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HomeMy Public PortalAbout5029 GLICKMAN AVE_Plumbing__ DBS-17 r f0-.,5 APPLICATION FOR PLUMBING PERMIT 1 DBS-17 JXVISION OF BUILDING AND SAFETY 41 Department of County Engineer County of Los Angeles BUILDING JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS CASSATT D,GRIFFIN,SUPT OF BUILDING '�, LOCALITY OR APPLI ANT TO FILLIN NEAREST CROSS ST. + OWNER DISTRICT NO. GROUP I ZONE RCADY FOR INSPECTION MAIL 1 �i ADDRESS 2 '�- it / jar INDUSTRIAL CITY TEL. NO 1 fG /J WASTEAPPROVAL PLUMBER ., �- 2 INSPECTION RECORD ADDRESS G CITY TEL. NO. LICENSE `' d NUM�BEjR' TYPE OF FIXTURE OR ITEM FEE ,0� a�'' r` WATER CLOSET (TOILET) @ $1.00 �' c J 1 BATH TUB @ $1.00 SHOWER @ $1.00 LAVATORY (WASH BASIN) @ $1.00 •-> KITCHEN SINK @ $1.00 DISHWASHER @ $1.00 LAUNDRY TUB OR TRAY @ $1,00 CLOTHES WASHER @ $1.00 ` WATER HEATER @ $1.00 GAS SYSTEM @ $1.00 , APPROVALS DATE INSPECTORS SIGNATURE UNDER SLAB WORK PERMIT $ 1 00 - ROUGH PLUMBING - GAS PIPING TOTAL FEE GAS VENT I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION HOT WATER HEATER AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING `' __�✓'' f PLUMBING, PLUMBING FIXTURES '•';jn ,i'-' IHEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR GAS TEST LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE UTILITY CO.NOTIFIED DESCRIBED RESIDENTIAL PROPERTY SIGNATURE /� OF PERMITTEE FINAL JOHN A.LAMBIE, COUNTY ENGINEER V� ALIDATION ROBERT A.WOOD, CHIEF PLBG. INSPECTOR CH.! N.0. CASH 0 6 3 0 2 U ;,W,2 2 3 4.0 0 to ION 20-0026 WORKER'S I have a certificate of consent to 76A667A PW 989 APPLICATION! FOR PLUMBING PERMIT 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:aJF 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 co © k f copy is filed with the county building inspection ADDRESS � (,G department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date Applicant WATER CLOSET -Y r L NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' r BATH TUB ROSS ST. COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the work involved by the SHOWER AP BOOK '' �j ( PAGE PARCELQ� permit is for one hundred dollars($100)or less.) WNER &n �� I certify that in the performance of the work for which this permit LAVATORYx fill is issued, I shall not employ any person in any manner so as to SINK AIL y� become subject to the Workers' Compensation Laws. ADDRESS DISWASHER CITY Date Applicant CLOTHES WASHER UU D�7 NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOR Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with such ADDRESS provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATIONCITY TEL.NO.- hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER � t ®. (commencing with Section 7000) of Division 3 of the Business and STATE LIC. 0 Professions Code, and my license is in full force and effect. GAS SYSTEM OUTLETS LICENSE NO. CLASS V P DISTRICT NO .. F OCESSED BY OUTLETS OVER ... � 5 PER SYSTEM /� � w FBS(:t o t License Number Lic.Class - f n�•I FINAL - �G' DATE VALID.�T�# - LU j2 Contractor Date n�� r'l ' 0- ❑ 1 am exempt under Sec. BY AL �' i I?I AL 7 0.:m 65Z CA' _r'3 B.&P.C.for this reason j / : Plan check fee '-_H •A AGE-. .. o CIO Date: Signature PLUMBING PERMIT ISSUING FEE$ /n► _- r-1TOTALFEE )t i t I- i ?Z 6 .141 Y�; Plan check applicant I ^`" € Ar yi I SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions Address Code): ❑ City Tel.No. I, as owner of the property,will do the work and the structure is not intended or offered for sale (Section 7044, Business and Professions Code). , 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 property for inspection purpos SEE REVERSE FOR EXPLANATORY LANGUAGE Sig ature of Permittee ! ate