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Home My Public Portal About5465 GOLDEN WEST AVE_Plumbing__ 76A667 (CE-817) - 1/75 ' /) APPLI6ATIOW�OR PLUMBING PERMIT COUNTY OF LOS ANGELES DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION MAKE CHECKS PAYABLE TO: BUILDING 574& ADDRESS HARVEY T. BRANDT, COUNTY ENGINEER LOCALITY P F- I V FOR APPLICANT TO FILL IN (PRINT OR TYPE) NEAREST ^^''','' CROSS ST. NUMBER FIXTURE OR ITEM @ FEE OWNER r^ ay WATER CLOSET 2.00 MAIL BATH TUB 2.00 ADDRESS SHOWER 2.00 CITY '" /1fF " TEL. NO. ��22 s LAVATORY 2.00 CONTRACTOR SINK 2.00 )Q ADDRESS AIL DISHWASHER f 2.00 CITY I TEL. NO. ` CLOTHES WASHER 2.00 ® STATE V LIC . SWIMMING POOL RECEPTOR 2.00 LICENSE NOCLASS DISTRICT NO.GROUP aONE —PROCESSED BY LAWN SPRINKLER SYSTEM 2.00 /_ ) l' / WATER HEATER 2.00 6,, INDUSTRIAL WASTE APPROVAL GAS SYSTEM OUTLETS 2.00 j lj c2 INSPECTION RECORD OUTLETS OVER v 5 PER SYSTEM .30 • O U W CL N Plan check fee See Reverse PLUMBING PERMIT ISSUING FEE $ TOTAL FEE APPROVALS DATE INS,PECTO R'S SIGNATURE [Address lan check applicant UNDER SLAB WORK ame ROUGH PLUMBING GAS PIPING LRESIDEN Tel. NO. GAS VENT HOT WATER HEATER REBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION ATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY PLUMBING FIXTURES LL COUNTY ORDINANCES AND STATE LAWS REGULATING G. GAS TEST REBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR UTILITY CO. NOTIFIED D AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF NIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO IN THE ABOVE DES IBED RE SIDEN�PROPERTY• FINAL s� T—77 TU REERMITTEE PERMIT VALIDATION CK. M,O: CAS . PLAN CHECK VALIDATION CK. M.0. CASH 2 z 21,pp s 5 D 1 6,5 0 �Q 76Gf667A CE 817(REV.6/78) �S APPLICATION ®®LICATION FOR PLUMBING LUMBING PERM 1T COUNTY OF LOS ANGELES BUILDING A D SAFETY FOR APPLICANT TO FILL IN(PRINT OR TYPE( BUILDING ADDRESS �YCs'�� NUMBER FIXTURE OR ITEM @ FEE WATER CLOSET LOCALITY NEAREST / BATH TUB 1 CROSS ST. SHOWER OWNERMAIL LAVATORY 13 ADDRESS SINK CITY TEL,NO, DISHWASHER CONTRACTOR � �^ �'� CLOTHES WASHER ADDRESS SWIMMING POOL RECEPTOR CITY TEL.NO. LAWN SPRINKLER SYSTEM STATE LIC. WATER HEATER LICENSE NO. CLASS GAS SYSTEM OUTLETS APPROVALS DATE INSPECTOR'S SIGNATURE OUTLETS OVER UNDER SLAB WORK 5 PER SYSTEM ROUGH PLUMBING GAS PIPING d ' GAS VENT I� HOT WATER HEATER 0 PLUMBING FIXTURES GAS TEST Z57—/I � �y" p Plan check fee UTILITY CO.NOTIFIED 1 PLUMBING PERMIT ISSUING FEE$ TOTAL FEE FINAL Plan check applicant PLAN CHECK VALIDATION Name Address City Tel. No. I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE /1 THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES V AND STATE LAWS REGULATING PLUMBING. PERMIT VALIDATION •- r O C O C, O 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 q �, ry O 0 LEGAL OWNER OF,AND INTEND TO RESIDE IN THE ABOVE DESCRIBED RESIDENTIAL G G, PROPERTY. 22. Oc� 'y SIGNATURE OF PERMITTEE Qird � "�fc DISTRICT NO. RO_CEESSSEED BY INDUSTRIAL WASTE APPROVAL WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby affirm tRat I have a certificate of consentl 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. ❑ 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 @ FEE111, LOCALITYTE � .'► - Date Applicant WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. ,4 COMPENSATION INSURANCE SHOWER OWNERUot_r 15WFrZ_ (This section need not be completed if the work involved by the permit is for one hundred dollars ($100)or less.) LAVATORY MAIL ADDRESS I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK CITY TEL. NO.02,VS-82,ZZ so as to become subject to the Workers Compensation Laws. DISHWASHER �/ CONTRACTOR Date/e OZ5 Applicant) � CLOTHES WASHER NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR Compensation provisions of the Labor Code, you must forth- CITY TEL. NO. LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE LIC. deemed revoked. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL-7 VALIDATION DAT License Number Lic. Class FI � Contractor Date ❑ N' I am exempt under Sec. �' 8.8P.C. for this reason Plan check fee Date: PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE SINGLE FAMILY l^ A Plan check applicant ;20 9 4 1 'A HOME OWNER-BUILDER DECLARATION Name # o o o .o 5 1 hereby affirm that I am exempt from the Contractor's License Address Law for the following reason (Section 7031.5, Business and ( - 2250 Professions Code): City Tel. No. ❑ I, as owner of the property, will do the work and the o ° -.2250F=' structure is not intended or offered for sale (Section ® 1 0,23-84 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 a ove-mentioned property for inspection purposes. - SEE REVERSE FOR EXPLANATORY LANGUAGE to Signature of Permittee Date WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I 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 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 r Certified copy is filed with the county building inspec- ADDRESS 7�� Zt= CC/67 NUMBER FIXTURE OR ITEM @ FEE tion department, LOCALITY��/Ga �_rh WATER CLOSET '� Date Appligant NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. ' GCJ y COMPENSATION INSURANCE SHOWER OWNER (This section need not be completed if the work involved by MAIL .d the permit is for one hundred dollars ($100)or less.) ! LAVATORY S ADDRESS �F�v S CO�O / I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner IF SINK CITY��if® � 7 TEL. so as to become subject.to the Workers'Compensation Laws. DISHWASHER CONTRACTOR Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR t Compensation provisions of the Labor Code, you must forth- CITY TEL. NO. LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE LIC. deemed revoked. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. OCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS O (� (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER C� and Professions Code,and m license is in full force and effect. 5 PER SYSTEM. FINAL VALIDATION 90 Z� License Number Lic. Class DATE 0. �. FINAL Contractor Date BY 0 ❑ I am exempt under Sec. V B.BP.C. for this reason ELIPlan check fee ® Z Date: PLUMBING PERMIT ISSUING FEE$ s Signature TOTAL FEE Plan check applicant SINGLE FAMILY `(' '�'1 "�•` ; HOMEOWNER-BUILDER DECLARATION Name " i" i"`{"`" I hereby affirm that I am exempt from the Contractor's License Address '"�h'f�t^'L - -•''-i' 'm '•-a'r Law for the following reason (Section 7031.5, Business and _ M rti Professions Code): "'€•;'-CK City Tel. No. -CHECK _ 1, as owner of the property, will do the work and the f ;"!?i"F l•f j) structure is not intended or offered for sale (Section '"!' '7')' 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 f a "" (Sec. 3097, Civ. C.). !': :: K ;...! rt `,,�,•._ IT Lender's Nome ri is+ ", :' .r " - Lender's Address -G-y ,-:- I certifythat I have read this application an "state that the 'r'-` above information is correct. I agree to comply with all County ordinances and State laws regulating Plumbing, and hereby 1A authorize representatives of this County 4A In}er upon the ;+p ab -mention pr t for inspection ptrposes. TOTAL 5�t� I•.j L� :�T it r SEE REVERSE FOR EXPLANATORY LANGUAGE Signature f Permittee -t`• +•Date .i'f _�fi-'.:S•.lE_ a-.._