HomeMy Public PortalAbout5528 GOLDEN WEST AVE_Plumbing__ 76A667 (CE-617) - 1/75 Ci �-\� C J� L Q•�
APPLICA"T"ION FOR PLUMBING, P RMI '
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER 1.
BUILDING AND SAFETY DIVISION _
MAKE CHECKS PAYABLE TO: ADDREDING
SS
HARVEY T. BRANDT, COUNTY ENGINEER
LOCALITY
c_.
FOR APPLICANT TO FILL IN (PRINT OR TYPEI NEAREST L
CROSS ST.
NUMBER FIXTURE OR ITEM @ FEE OWNER
WATER CLOSET 2.00 1 QXr45
MAIL Bj��
BATH TUB 2.00 ADDRESS
SHOWER 2.00 CITY' �� TEL :D r.w}
LAVATORY 300 CONTRACTOR / ism
SINK 2.00 ADDRESS
DISHWASHER 2.00CITY Mn TEL. NO. Q
CLOTHES WASHER 2.00 STATE j (} LIC
LICENSE NO. jj CLASS
SWIMMING POOL RECEPTOR 2.00
DISTRICT NO.GROUP ///ZONE (R7OESSED BY
LAWN SPRINKLER SYSTEM 2.00 y� U L? OZONE
7 2uv `
d' WATER HEATER 2.00 INDUSTRIAL V
WASTE APPROVAL
GAS SYSTEM OUTLETS 2.00 INSPECTION RECORD d
OUTLETS OVER CD
5 PER SYSTEM .30 C>
CD
L3
U
I W
a
N
Plan check fee See Reverse
PLUMBING PERMIT ISSUING FEE $ b
TOTAL FEET
APPROVALS DATE INSPECTOR'S SIGNATURE
Plan check applicant UNDER SLAB WORK
Name ROUGH PLUMBING
Address GAS PIPING
City Tel. No. GAS VENT
HOT WATER HEATER
I HEREBY ACKNOWLEDGE THAT I HAVE READ .THIS APPLICATION
AND STATE THAT THE ABOVE-IS CORRECT AND AGREE TO COMPLY PLUMBING FIXTURES
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING. GAS TEST
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR UTILITY CO. NOTIFIED
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 PROPERTY. FINAL
SIGNATU RE_
OF PERMITTEE � i (
PERMIT VALIDATION CK. M.O: CASH
PLAN CHECK VALIDATION CK. M.O. CASH
�. v•WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING M BIND If— RMI
l hc" Y �Ffisrre that I have a certificate of consent to self 76A667A
,,;sure, ciy a certificate of,Workers Compensation Insurance, CE 817(REV. 10/8))
1'�6certified cop thereof ec. 8 Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
WC SB—
Policy No. ®•~ CompanyU-11q!
❑ Certified copy is hereby furnished. Q
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 C
Date 07-40 7 • Applicant ✓✓� w �,t1 WATER CLOSET r
NEAREST �/�
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB 00 CROSS ST. 1W(- v(.,
COMPENSATION INSURANCE SHOWER M00 Izen,
OWNER �' f
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars ($100)or less.) LAVATORY ® ADDRESS E- Lei r,
1 certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK ®® CITr' TEL. N�
so as to become subject to the Workers'Compensation Laws. DISHWASHER
00 CONTRACTOR/'°\ m �� f
Date Applicant CLOTHES WASHER v ' 1
NOTICE TO APPLICANT: If, after making this Certificate of ADORES1!9 a
Exemect to t
you s
,tionhould become sub he Workers' SWIMMING POOL RECEPTOR
P Y I CITY � TEL. NO.
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM 1
with comply with such provisions or this permit shall be STATE LIC,
deemed revoked. WATER HEATER �r4 LICENSE NO. �� CLASS
LICENSED CONTRACTORS DECLARATION V DISTRICTNO. '/ CE ED BY
`/(�[
I hereby affirm that I am GAS SYSTEM OUTLETS licensed under provisions of Chapter 9 V 000
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code, and my license is in full force and effect. 5 PER SYSTEM FINAL O VA IDATION
//ii �� DATED
License Number Lic. Class 2 0
FIN
Contractor Date B
Q.'
❑ I am exempt under Sec.
B.BP.C. for this reason W
Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$ J�
Signature 7 5 4.3 A
TOTAL FEE
Plan check applicant .#to 0 0 0;0 5
SINGLE FAMILY0 Z (�
HOME OWNER-BUILDER DECLARATION Name G 0./v
I hereby affirm that I am exempt from the Contractor's License Q 7.2 8a 8
Law for the following reason (Section 7031.5, Business and Address
Professions Code): City Tel. No.
❑ I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY 'r
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 pool
ordinances and State laws regulating Plumbing, and hereby
jS'
uthorize rept sentatives WtOounty to enter upon the
e-men ' ed pro yctionpurposes.
_,,poses.
SEE REVERSE FOR EXPLANATORY LANGUAGE
nature of Per to ate