HomeMy Public PortalAbout4929 GOLDEN WEST AVE_Plumbing__ 76A667 (CE-817) - 1/75
APPLICATION FOR"PLUMBIAG PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
MAKE CHECKS PAYABLE TO: ADDRESS
HARVEY T. BRANDT, COUNTY ENGINEER
LOCALITY�'�
FOR APPLICANT TO FILL IN (PRINT OR TY PEI NEAREST
4 CROSS ST. ---J4 nS
NUMBER FIXTURE OR ITEM @ FEE G/
/ WATER CLOSET 2. 0 OWNER ✓ ` 0e
MAIL �f
2. -
BATH TUB 0 ' �� ADDRESS
SHOWER 2.)0 O CITY7'� C, '$,fEL. NO. 8 -7jiyl7
LAVATORY 2. 10 CONTRACTOR
SINK 2.)0 ADDRESS
DISHWASHER 2.)0 CITY JPVTEL. NO.
CLOTHES WASHER 2.)0 STATE LIC
SWIMMING POOL RECEPTOR 2.)0 LICENSE NO. CLASS
DISTRICT NO.GROUP NE PR CESSED BY-
LAWN SPRINKLER SYSTEM27
. 0 ' 08
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WATER HEATER 2, 0 INDUSTRIAL
WASTE APPROVAL a
GAS SYSTEM OUTLETS 2.bo o o INSPECTION RECORD V
OUTLETS OVER
5 PER SYSTEM .30 _- /,`.,�'.- �O
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Plan check fee See Reverse
PLUMBING PERMIT ISSUING FEE $
TOTAL FEE .�l-1
APPROVALS DATE INSPECTOR'S SIGNATURE
Plan check applicant UNDER SLAB WORK
Name ROUGH PLUMBING
Address GAS PIPING
City Tel. No. GAS VENT
HOT WATER HEATER
I HEREBY ACKNOWLEDGE THAT I HAVE READ -THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY PLUMBING FIXTURES
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING. GAS TEST
-I HEREBY CERTIFY THATLOAM AM PROPERLY REGISTERED AND/OR UTILITY CO. NOTIFIED
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF d
77
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO
RESIDE IN THE ABOVE DESCRIBED RESIDENTIAL PR�RTY, FINAL j':=` y - -�
SIGNATURE _ - ,. -� -
OF PERMITT-- r
PERMIT VALIDATION CK. 0. ASH
PLAN CHE VALIDATION CK. M.O. CASH
0 1 3 r+T 4- 5 u 2 25 L) � '.;
Vip-RKERS'COMPENSA-171ON DECLARATION APPLICATION F R M B PLUMBING P E RM I T
�lgpraby, m that I haves certtflcat9 of consent to self In- , °P"440 OR LU G
sur►, qr a cprtff�cgte pf Worker3'Cbmpentatlon Insurance,or a
certified copy eof(ske, 3800, Lab. C. 1
Policy No.1/10" ompany COUNTY OF LOS ANGELES DEPT.'OF PUdL1C WORItS_
Certified copy Is hereby furnished. Z
FOR APPUCAM TO HLLJN(PRINT OR TYPE) BUILDING
Certified copy Is411ed with fhe coup bel Ing Inspection NUMBER R)fUOfM ASS
de a FEE �.�
LOCALITY
oat. 1a Applicant WATER CLOSET(fOiLET)
CE FICATE OF EXEMPTION WORKERS' BATH TUB CROSS
COMPENSATION INSURANCE SHOWER OWh62
(Thls 94KO n need not be completed If the work tnvolved by MAIL
the permFt Is for one hundred dollars (;100)or loss.) LAVATORY ADDRESS
I certify that In the performance of the work for which this Per- SJNIK ClTY TEL NO �D
mit Is Issued, I shall not employ any person In any manner to
as to become subject to the Workers Compenscrtlon Laws. DISHWASHER �
Date. Applicant CLOTHES WASHER
NOTICE TO APPUCANr: If, after making this Certificate of Ex- ADDRESS
emptlon,you should become subject to the Worker'Compen- SWIMMING POOL RECEPTORCTfY TEL NO
sation provisions of the Labor Code,you mutt forthwith comp- LAWN��ER SYSTEMS , O
ly with such provisions or this permit shall be deemed revok- STATE UC_
ed. WATER HEATER UCgtSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OLMLEfS O
9(commencing with Sectlon 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code, and my license Is in full force and ef- FINAL VALIDATION
fect. H435EBIB DATE `)—
License Number 2LIc Class d
FINAL '� O
U
Cohtractor Date BY fT.i d
/ 1i O
❑
I am exempt under Sec. La d ]" w.
B.BP.C, for this reason Plan check fee Opp Lu
ITEM a
Date: PLUMBING PERMIT ISSUING F�$ o2 A D TOTPL $$ 20
Signature TOTAL FEE .2 Q C�ECX
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Plan check applicant CA'G .CC
I hereby affirm that I am exempt from the Contractor's License Name
Law for the following reason (Sectlon 7031.5, Business and
Professions Code): Address ]-4)01]1 5/12/94
I, ai owner of the property, will do the work and the City Tel. No. 5169 1 AM 3:1S
structure le not Intended or offered for sale(Sectlon 7044,
Business and Professlons Code).
t
CONSTRUCTION LENDING AGENCY
I hereby affirm that there Is a construction lending agency.for
the performance of the work for which this permit Is Istued
(Sec. 3097, Civ. C.).
Lender's Name
Lenders 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
auth Ize representatives of this County to enter upon the
a mention property for Inapectlon pu
SEE REVERSE FOR EXPLANATORY LANGUAGE
i
Signature o P r to 4