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Home My Public Portal About5303 GOLDEN WEST AVE_Plumbing__ 76A667 -CE#'817 2-62 7r i�� .'iY L E 9 y�lyi APPLICATION FOR PLUMBING PERMIT COUNTY OF LOS ANGELES DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING ADDRESS �✓O 'CY�6 r/ Y�l'E�7, JOHN A. LAM BI E, COUNTY ENGINEER WILLIAM A. JENSEN. SUPT OF BUILDING LOCALITY FOR APPLICANT TO FILL IN NEARESsT CROSS T. NUMBER FIXTURE OR ITEM EACH FEE WATER CLOSET $1.25 y /` OWNER 06 ✓/r�/xi/� il: �' MAIL , J BATH TUB 1.25 ADDRESS CITYa7TEL. NO.4 ,Z SHOWER 1.25 LAVATORY 1.25 CONTRACTOR SINK 1.25 ADDRESS DISHWASHER 1.25 CITY TEL. NO. LAUNDRY TUB 1.25 CONTRACTOR'S STATE ❑ REGISTRATION NO. COUNTY ❑ CLOTHES WASHER 1.25 DISTRICT NO. GROUP ZONE P. ESSED BY WATER HEATER 1.50 (1 1" ( GAS SYSTEM OUTLETS 1.50 INDUSTRIAL WASTE APPROVAL OUTLETS OVER 5 PER SYSTEM 30 INSPECTION RECORD O Lu APPROVALS DA T E INSPECTOR' SSI NATURE PERMIT $ 2 OO UNDER SLAB WORK ROUGH PLUMBING V VAU TOTAL FEE GAS PIPING - 1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY GAS VENT WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING HOT WATER HEATER PLUMBING. I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR PLUMBING FIXTURES LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF GAS TEST CALIFORNIA OR THAZT T LEGALOWNE F,A I D TO RESIDE IN,THE ABOVSC D RESIDENT ROP Y c UTILITY CO. NOTIFIED SIGNATURE } w a4 OF PERMITTE FINAL �� LIDATION ROBERT A. WOOD CK. M.0. CASH SUPERVISING MECHANICAL ENG'R L_i1v0 4 5 3 1 -PAY 10 5 G 5.75- {:. WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a certificate of consent to self 76A667A insure, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81) or a certified copy thereof (Sec. 3800, Lab. C. COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company Certified copy is hereby furnished. F-1Certified APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy is filed with the county building inspec- ADDRESS C)( DkAJ WQ tion department. NUMBER FIXTURE OR ITEM rr FEE LOCALIT BM t C- Date Appligant WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB' CROSS ST. Z_ y T COMPENSATION INSURANCE SHOWER OWNER (This section need not be completed if the work involved by the permit is for one hundred dollars $100 or less. MAIL P ( ) ) LAVATORY _� ADDRESS CoeDCA-i -dq os I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK CITY_--/'e TEL. NO. so as to become subject to the Work rs Compensation L s. DISHWASHER � CONTRACTOR�Y L(�2 ` �! C Date �' Applicant CLOTHES WASHER NOTICE TO APPLICANT: If, after aking this Cer' tate of ADDRESS /� Exemption, you should beco subject to the Workers" SWIMMING POOL RECEPTOR Compensation provisions of th abor Code, ou must forth- CITY ,I' TEL. NO. p p y LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE �/ LIC. +� deemed revoked. WATER HEATER LICENSE NO. �,j�j°Y CLASS C 1-3 LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS -� (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDATION. DATE License Number cSLic. Class �'� � � �� FINAL / Contractc,' ,h/ o� Date-&ID I am exempt under Sec. CID B.BP.C. for this reason Plan check fee Date: PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE Plan check applicant SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name r Q 2 ,A I hereby affirm that I am exempt from the Contractor's License Address :'`. o'c o 0 0 Law for the following reason (Section 7031.5, Business and , Professions Code): City Tel. No. vo 3. F ElI, as owner of the property, will do the work and the structure is not intended or offered for sale (Section 5 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 obov -mention ;prro erne inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE nature of Permit t Date