HomeMy Public PortalAbout5105 GOLDEN WEST AVE_Plumbing__ Vb'IJ75
76A607-CE817 10-60
APPLICATION FOR PLUMBPERMIT )
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE. COUNTY ENGINEER ADDRESS 5105 N. Golden gest
WILLIAM A. JENSEN, SUPT OF BUILDING
LOCALITY Temple Cit
FOR APPLICANT TO FILL IN NEAREST
NUMBER FIXTURE OR ITEM CROSS ST.
WATER CLOSER OWNER jam, Mrs alaZZa
BATH TUB ADDRESS 5105 N. Golden West
1 SHOWER CITY Temple City TEL. NO.
1
LAVATORY CONTRACTOR Belvedere Plumbin Co.
SINS ADDRESS11900 R. Garvey Ave.
DISHWASHER CITY El lAonte TEL. NO. IM CU 31691
LAUNDRY TUB REGISTRATION NO. 179568 COUNTY ❑
CLOTHES WASHER DISTRICT NO. GROUP I ZONE P CESSED BY
WATER HEATER ,
GAS SYSTEM INDUSTRIAL
WASTE APPROVAL
INSPECTION RECbRD D_
O
V
GO
lif
a.
$1.00 PER ITEM
3 OR FIXTURE $ n
3.oO APPROVALS DATE INSPECTOR'S SIGNATURE
- PERMIT $ 2 00 UNDER SLAB WORK /I-
TOTAL
TOTAL FEE ROUGH PLUMBING
GAS PIPING
t 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
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 1 AM THE LEGAL OVYNF�R OF THE ABOVE
DESCRIBED RESIDE In PROPERTY.
SIGNATURE 1 UTILITY CO.NOTIFIED
��
OF PERMITTEE UL
INAL
VALIDATI N ROBERT A. WOOD
CK.
M.0. CASH SUPERVISING MECHANICAL ENG'R
6.
5 2 2 : NOV 30 5 0 5.00
)&ORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT f(
1 hereby affirm that I have a certificate of consent to self 20-0026 DPW 6/87
insure, or a certificate of Workers' Compensation Insurance, 76A667A U
or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No. Company
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ,yGC���C�G{2aK�S�
17 Certified copy is filed with the county building inspec- ADDRESS S'
tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
WATER CLOSET
Date Applicant NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE OWNER
SHOWER
(This section need not be completed if the work involved by { 1 f� A
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESMAILS / ' AeA
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in an manner SINK 0 CITY '7iB�T� TEL. NO.
so as to become subject to the Wo kers'Com ati n Laws. ( DISHWASHER U �L
CONTRACTOR
CR
Date Applicant CLOTHES WASHER V ADDRESS
NOTICE TO APPLICA T: If, after aking this Certifica of
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
CITY TEL. NO.
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETSda�
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER `J }.
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL z VALIDATION k17pi
DATE �/ U
License Number Lic..Class 0
FIN X
Contractor Date BY
❑ R
1 am exempt under Sec. C3,
B.&P.C. for this reason
Plan check fee ► N
Date: Z.
PLUMBING PERMIT ISSUING FEE$
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 Address
Law for the following reason (Section 7031.5, Business and
Professions Code): City Tel. No.
1, 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 St ws regulating Plumbing, and hereby
authorize re pr ent iv sof this County to enter upon the
above-mention pr erty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
ilk. L �_
&ilgnotu of Permitte ate