HomeMy Public PortalAbout5147 GOLDEN WEST AVE_Plumbing__ 76A667 -CE0817 4-64 1 C
APPLICATION FOR PLUMBING PERMIT.
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER J `,
BUILDING AND SAFETY DMSION / / /1'`
JOHN A. LAMBIE, COUNTY ENGINEER j
ADDRESS
WILLIAM A JENSEN, SUPT OF BUILDING
LOCALITY ,�E✓l�ps`r C ,r
FOR APPLICANT TO FILL IN NEAREST O
CROSS ST. o
NUMBER FIXTURE OR ITEM EACH FEE
WATER CLOSET $1.25 14AILAIL �` r. ���
M
BATH TUB 1.25 ADDRESS
CITY TEL. NO.
SHOWER 1.25
LAVATORY 1.85 CONTRACTOR Pfje lok oe>2&
SINK 1.25 ADDRESS .5��- X
DISHWASHER 1.25 CITY_ .ep'o+L V,&,)"i TEL. NO.S 7-
CONTRACTOR'S
- f��"
STATE
LAUNDRY TUB 1.25 REGISTRATION NO. p�I �� COUNTY ❑
CLOTHES WASHER 1.25 DISTRICT
/�NO. GROUP ZONE PROCESSED BY
WATER HEATER 1.50 '
a3 f k of
GAS SYSTEM _OUTLETS 1'5 INDUSTRIAL °-
WASTE APPROVAL O
OUTLETS OVER 5 PER SYSTEM .30 INSPECTION RECORD �� V
10
c 9 V
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APPROVALS DATE INSPECTOR'S SIGNATURE
PERMIT 2 00 UNDER SLAB WORK
ROUGH PLUMBING �-
TOTAL FEE 3 -50 GAS PIPING
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION GAS VENT • _ ,
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING HOT WATER HEATER
PLUMBING
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR PLUMBING FIXTURES
LORTHA� .A
S REQUIRED BY LOS ANGELES COUNTY AND STATE OF GAS TEST
I THE LEGAL OWNER OF,AND INTEND TOHE AB VE RIBED RESIDENTIAL PRO ERTY UTILITY CO NOTIFIEDE
ITTE ��
.FINAL ��� ,
LIDATION ROBERT A WOOD G
CK M OI CASH SUPERVISING MECHANICAL ENG'R
., Lo 1 7 1 4 MAY 17 5` a 3.5 QCQ
Y` WORKERS'COMPENSATION DECLARATION , ,APP"LIGATION -FOR PLUMBINGPERMIT
I hereb';=affirm that`I have a'certrficate'of consent to self ink 20;0026 DPW�4/,87,
Y" 76A667A a
sure,-or a certrfic(5te of Workers'Compensation Insurance,or a, .CE 817(REV 8%86)
certified c/oyp)y therenof;(Sec 3800, Lab C )
Policy.NcA�9 / Z.
Company; COUNTY OF'LOS ANGELES• _ DEPT. OF.PUBLIC^�WORKS`, _ Y r
Celtified copy is hereby furnished
" FOR APPLICANT TO FILL IN(PRINT OR-TYPE) BUILDING'
CLrtlfled-copy is filed with-the county_bui[ding inspectionADDRESS
:de artmenf NUMBER FIXTURE OR ITEM @, FEE
R �`�• LOCALI Y
Date Applicant { WATER CLOSET(TOILET) } NEAREST
BATH
CERTIFICATE OF EXEMP,TIONtFROM WORKERS' • TUB CROSS ST�- -`t�, � ,��„4���, �..• '
t { `_",-'',':COMPENSATION INSURANCE,"'•,a+ ., err= t. .,'_,,OWNER .M�-
SHOWER
(This section need not be completed if{he•work involved'by MAIL '.? 4 -L '0N "'
the permit-is foi one hundred dollars'($100)or•less.) LAVATORY ADDRESS' �tTC'' r' -
I•certify,thatyiri the performancevf tl e work'fowhich this per- SINK { ,t' CITY ” °c TEL NO 01
SI
mit is.issued,=I shall not employ any'person,in ary'manneiso
as to become sublect to the Workers' Corpensahon-Laws' - " DISHWASHER
i`• - . - .; " - CONTRACTOR 0 ,
Ap
Date`, plicant ', y sCLOTHES,WASHER,
NOTICE TO,APPLICANT 'If, after+mak`ing'this Certificate of Ex- ticADDRE55 "
emphon,'y6u should become sublect to the Workers'Compen- SWIMMING POOL RECEPTOR ?,
-'sation•provisions of the;Labor Code, you�must,forthwith comp`; LAWN SPRINKLER SYSTEM CITY 60y/Na TEL N01
ly'with such provisions.or this•perniit shall be deemed revok-- - STATE LIC Qb
ed a' - ; WATER'HEATER ' LICENSE NO �� 3 - LASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO PROCESSED BY
GASSYSTEM OUTLETS F'
1 h`ereby'aff+rm that I am licensed under,provisions of Chapter .3.
mmencing with Section 7000)of Division 3 of the Business c,''- „OUTLETS OVER• ''
and Professions Code, and my license-is in full force and'ef- :5 PER SYSTEM' l f FINAL d a
feet DATE — -V IDATION' a
License Number lSO / Lie"Claes.
7 :. .•. FINAL
Contractor Date l * 1 BY 4 Q
I•am ezemp under SecUJI
CL
B 8P C'+foi t' sFreason 't
'Plan checkfee'.: ®.
0'2`x'7 A
Date t PLUMBING PERMIT ISSUING FEE$
-q"'Signatur,e +' rmle
'TOTAL^FEE # o ° 0 0 0'5_•SINGLE FAMILY HOME OWNER-BUILDER DECLARATIONt ' ° 3.4,J'OI Hereby affirm,that I,am exempt from the Contractor's'License3 ,ti3-4.5 0 a .•0 00Law for thiiNbllowing reason,(Sect16n,7031 5"Business'and '` Y a.Piofessions Code)I, as owner of,the property, will dotthe work and the' -� 'Tel No r, Q7•� tj s a a r
'structure is not intended or,offereclfor sale-(S
ection 7044;,
- .Bu`siiness and Professions Code) `✓ - j°
CONSTRUCTION'LENDING AGENCY`
I-Hereby aiffirm'that there is a construction'lend ing:'agency•for
the performance of,the work;for which this permit is issued
(Sec '3097;-C+v C.)
Lende'r's Name"
Lender's,Address
I'certify:tha't'I.have'read this application,6nd,state that-i he
above inform' o6on)s correct I agree to comply with all County "
ordm6nces'and State laws regulating Plumbing,and hereby l -
• ' authorize,represent6tives of*this County to enter upon the a
above-' t ed property for, inspection"purposes _
9
�' SEE:REVERSE FOR*,EXPLANATORY LANGUAGE 1',
'Signature of Permit t Date