HomeMy Public PortalAbout5737 GOLDEN WEST AVE_Plumbing__ 76A667-CE817-11-57 J
_
APPLICATION FOR `PL' UMBING- PERMIT
COUNTY OF LOS-ANGELES -
DEPARTMENT OF..COUNTY ENGINEER
BUILDING AND-SAFETY DIVISION _ ` BUILDING.,o r
JOHN A. LAMBIE; County. En eer ADDRESS �3 ' �`
CASSATT D.4GRIF'FIN,-Sup County. Engin
Building LOCALITY
FOR-APPLICANT TO FILL IN- NEAREST f
CROSS ST.
NUMBER FIXTURE OR ITEM
'
WATER OWNER CLOSET MAIL
BATH TUB ADDRESS
SHOWER CITY y TEL NO. t -7
r LAVATORY CONTRA R ?� +�
Sig_, ADDRESS C�
DISHWASHER CITY TEL.
LAUNDRY' CONTRA R'S ����� STATE
REGIS
T TION NO. COUNTY ❑
CLOTHES WASHER
DISTRICT-NO., GROUP ZONE ,READY FOR"INSPECTION
ER
WATHEATERa �
GAS SYSTEM- INDUSTRIAL
WASTE APPROVAL
!� a INSPECTION RECORD
° APPROVALS
CA $1.00 PER ITEM DATE INSPECTOR'S SIGNATURE
OR FDCTURE a
c4 UNDER SLAB WORK
PERMIT 5 00 ROUGH PLUMBING
TOTAL FEE - eV GAS PIPING -
AGASHEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
VENT
D STATE THAT THE-ABOVE IS CORRECT AND AGREE TO COMPLY HOT WATER HEATER
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING. I I IPLUMBING FIXTURES
1 HEREBY CERTIFY"THAT, 1 AM- PROPERLY REGISTERED AND/OR GAS TEST
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA-OR THAT I AIi E LEGAL OWNER OF THE ABOVE UTILITY CO.NOTIFIED
DESCRIBED RESIDENTIAL/O RTY.
r
SIGNATURE
OF PERMITTE FINAL
ROBERT.4.WOOD. =`-
®" VALIDATION,, SUPERVISING MECHANICAL ENG'Ft,,#
CK. 6l.O. CASH
i �' _A 3.00 v
WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby, affirm that I have a certificate of consent to self in- 20-0026 DPW 4/90
76A667A
sure,or a certificate of Workers'Compensation Insurance,ora n
certified coy thereof JSec 3800�Lab C ) U
/ �' f � COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No ompany '
❑ Certified copy is hereby furnished
copy y g p FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING _,$>37
y�� Certified co is filed with the count building inspection ADDRESS
C� NUMBER FIXTURE OR ITEM LOCALITY
department @- FEE
Date T' 1.3 Applicant WATER CLOSET(TOILET) NEAREST —�
_ CERTIFICATE OF EXEMPTION FROM WORKERS'
BATH TUB CROSS ST �
COMPENSATION INSURANCE SHOWER OWNER
(This section need not be completed if the work involved by MAIL �
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS -• C7�'1 (LPy7
I certify that in the performance of the work for which this per- SINK �� � C"' �
mit is issued, I shall not employ any person in any manner so CITY _a f TEL N 1
as to become subject to the Workers'Compensation Laws DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR
emption,you should become subject to the Workers'Compen CITY TEL NO� °'�CYf
sation provisions of the Labor Code, you must forthwith comp-
LAWN SPRINKLER SYSTEMS rr�
ly with such provisions or this permit shall be deemed revok- STATE LIC
ed WATER HEATER LICENSE NO � CLASS
LICENSED'CONTRACTORS DECLARATION DISTRICT NO PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code, and m license is in full force and ef- 5 PER SYSTEM
Y FINAL VALIDATION -�-
feci HOSE BIB DATE
License Number J J Lac ClassC.--3v/pt-t3
T FFM3 O
FINAL
Contract,` �� Date BY
IT ET€�I_ 42 m 609
❑ � .t or-¢
I am exempt under Sec r � y; :d_O
B &P C for this reason �•HH U' of 110
Plan check fee , a
Date PLUMBING PERMIT ISSUING FEE$ ���/ 2
Signature
TOTAL FEE !�
SINGLE FAMILYOrt, til n`i j
HOME OWNER-BUILDER DECLARATION Plan check applicant
I hereby affirm that I am exempt from the Contractor's License Name
Law for the following reason (Section 7031 5, Business and
Professions Code) Address
❑ 1, as owner of the property, will do the work and the City Tel No.
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
authorizer presentatives of this County to enter upon the
above-me boned property for insction purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date