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HomeMy Public PortalAbout5405 GOLDEN WEST AVE_Plumbing__ I 7A CE B1 CE H17 1NE V.6/781 ©S 3— APPLICATION FOR PLUMBING PERMIT COUNTY OF LOS ANGELES BUILDING AND SAFETY FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING NUMBER FIXTURE OR ITEM @ FEE ADDRESS 54Qd'5-Go ld en "Wo at WATER CLOSET LOCALITY TM19 ,+.• NEAREST ,\ BATH TUB CROSS ST. SHOWER OWNER `'� � SILZ LAVATORY MAIL ADDRESS SINK CITY TEL.NO DISHWASHER CONTRACTOR CLOTHES WASHER ADDRESS SWIMMING POOL RECEPTOR CITY Y,, TEL.NO. r^ LAWN SPRINKLER SYSTEM STATE{ LIC. WATER HEATER LICENSE NO. `j �{• - CLASS `y GAS SYSTEM OUTLETS APPROVALS DATE INSPECTOR'S SIGNATURE OUTLETS OVER UNDER SLAB WORK d 5 PER SYSTEM ROUGH PLUMBING O GAS PIPING u W GAS VENT11611. J HOT WATER HEATER �. DC PLUMBING FIXTURES GAS TEST O Plan check feea UTILITY CO.NOTIFIED PLUMBING PERMIT ISSUING FEE$ TOTAL FEE FINAL Plan check applicant PLAN CHECK VALIDA ION Name Address City Tel.No. I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING. PERMIT VALIDATION I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWNER OF,AND INTEND TO RESIDE IN THE ABOVE DESCRIBED RESIDENTIAL 'e PROPERTY. SIGNATUREA OF PERMITTEE DISTRICT NO. PROCESSED BY ' INDUSTRIAL WASTE APPROVAL I WORKERS'COMPENSATION DECLARATION 76A667A I hereby aftirm that I have a certificate of consent to self CE 917 (2-60) APPLICATION FOR PLUMBING PERMIT insure, or a certificate of Workers'Compensation Insurance,or ' 'fied�py th eq(Sec.3800,Lab C.) y''ll COUNTY OF LOS ANGELES BUILDING AND SAFETY Poli No. ompany Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING. Certified copy is filed with the county b�ilding inspection NUMBER FIXTURE OR ITEM • FEE ADDRESS qt rt a WATER CLOSET LOCALITY e Applicant NEAREST BATH TUB CROSS ST. L� CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE SHOWER OWNER LAVATORY MAIL '� (This section need not be completed if the work involved ADDRES aA by the permit is for one hundred dollars ($100) or less.) O SINK CITY TEL. U I certify that in the performance of the work for which this DISHWASHER CONTRACTOR i cc permit is issued, I shall not employ any person in manner so b o e subject to th Vo I rs' o s n aws. CLOTHES WASHER a ,Ito�e ADDRESSnL lU DatE Applicant SWIMMING POOL RECEPTOR r1 NOTICE TO APPLICANT: If, after making J9his Certificate of CITY ( U) Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE .Compensation provisions of the Labor Code, you must forth- LICENSE NO.with comply with such provisions or this permit shall be WATER HEATERdeemed revoked. GAS SYSTEM OUTLETS DISTRICT NO. LICENSED CONTRACTORS DECLARATION OUTLETS OVER Si® I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM 9 (commencing with Section 7000)of Division 3 of the Busi- FINAL VALIDATION ness and Professions Code, and my license is in full force and DATE effect. FINAL /r License Numb e ic.Class BY Contractoroft Date EJI am exempt from the licensing requirements as I am a Plan check fee J �° licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$ acting in my professional capacity (Section 7051, Bus- iness and Professions Code). TOTAL FEE Lie.or Reg.No. Date Plan check ap lic nt HOME OWNER-BUILDER DECLARATION Name r I hereby affirm that I am exempt from the Contractor's Address License Law for the following reason (Section 7031.5, Busi- City Tel.No. 1 5 1,0 A ness and Professions Code): ❑ I, as owner of the property, am exclusively contracting o o 0 o o 5 with licensed contractors to construct the project (Section 7044, Business and Professions Code). 2 - ° 1 3,00 CONSTRUCTION LENDING AGENCY 0 0 0 1 a Q Q Q I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is t Q1 3-81 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 SEE REVERSE FOR EXPLANATORY LANGUAGE ordinances and State laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the mentioned property for inspection purposes. I Date gna reo ermittee ((