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HomeMy Public PortalAbout5459 GOLDEN WEST AVE_Plumbing__ 76A667A ICE 8178)- 11/76 APPLICATION N F R PLUMBING PERMIT BUILDIN A SAFETY DIVISION FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING NUMBER FIXTURE OR ITEM @ FEE ADDRESS S^ k e WATER CLOSET LOCALITY e. l._ --NEAREST BATH TUB CROSS ST. SHOWER OWNER LAVATORY MAIL ADDRESS JrF ", SINK CITY TEL.NO. DISHWASHER CONTRACTOR CLOTHES WASHER ADDRESS SWIMMING POOL RECEPTOR CITY TEL.NO ,.,::2 j-e �I LAWN SPRINKLER SYSTEM STATE LIC WATER HEATER LICENSE NO. CLASS GAS SYSTEM OUTLETS D`ST�NO. CY l ONE O4ESSED Y OUTLETS OVER 61J 5 PER SYSTEM INDUSTRIAL r WASTE APPROVAL O� INSPECTION RECORD 99 Plan check fee PLUMBING PERMIT ISSUING FEE$ TOTAL FEE Plan check applicant Name APPROVALS DATE INSPECTOR'S SIGNATURE O T UNDER SLAB WORK Add ress.,07,,OergS ROUGH PLUMBING City Tel.No. f,-50" GAS PIPING IHEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE GAS VENT THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING. - HOT WATER HEATER I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR LICENSED AS PLUMBING FIXTURES REQUIRED BY LOS ANGELES COUNTY AND STATE OF CALIFORNIA OR THAT I AM THE GAS TEST LEGAL OWNER OF,AND INTEND TO RESIDE IN THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. UTILITY CO.NOTIFIED SIGNATURE -5? �(//�� OF PERMITTEE 2� `�— FINAL PLAN CHECK VALIDATION CK. M.O. CASH PERMIT VALIDATION cK. M.0. CASH 4 7 2 5 D 1 0.5 G tl�50 ©s C-PaICE? o ' VkORKES'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT �' . I he y'gffir`�1°�• 1 I have a certificate of consent to self 76A667A - irfsu C�a tate 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. ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy is filed with the county building inspec- ADDRESS tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY TQM Pim c-tT{ WATER CLOSET Date Applicant CROSS ST. (fit S NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB COMPENSATION INSURANCE ®�SHOWER OWNER (This section need not be completed if the work involved by MAIL the permit is for one hundred dollars (;100)or less.) LAVATORY ADDRESS ���� I certify that in the performance of the work for which this permit is issued, l shall not employ any person in any manner SINK CITY. t Q C9 TEL. NO. so as to become subject to the Workers'Compensation Laws. DISHWASHER / CONTRACTOR '�_Z LA 1 l.,`7 X12 DateyApplicantl�9L�S�r11Jl�c1Q�V� CLOTHES WASHERA- GCO NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS (;:1 rnG Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR CITYs' ice TEL. NO. S Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM -)e- with comply with such provisions or this permit shall be STATE LIC. deemed revoked. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION �m.,. DISTRICT NO. R CESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS ®�Y ) (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER ` and Professions Code,and m license is in full force and effect. 5 PER SYSTEM FINAL —10-7 y DVALID ATE ION License Number Lic. Class U FIN @9 Contractor Date BY El I am exempt under Sec. B.&P.C. for this reason Plan check fee � g Date: PLUMBING PERMIT ISSUING FEE$ Signature ;92279A TOTAL FEE Plan check applicant # 000005 SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name i - - 5250 1 hereby affirm that I am exempt from the Contractor's License Address La for the following reason (Section 7031.5, Business and .0 0 - 52505 Pr essions Code): City Tel. No. I, as owner of the property, will do the work and the Q 618"85 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 State laws regulating Plumbing, and hereby authori epres tatives of this County to enter upon the above noon property for ' spection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE xy fature o Permittee Date