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HomeMy Public PortalAbout5753 GOLDEN WEST AVE_Plumbing__ 76A667 (CE-817) - 1/75 -� APPLICATIO OR PL BING PERMIT COUNTY OF LOS ANGELES DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION MAKE CHECKS PAYABLE TO FADDRESS 57531AGOLDEN WESTHARVEY T. BRANDT, COUNTY ENGINEERFOR APPLICANT TO FILL IN (PRINT OR TYPE) NUMBER FIXTURE OR ITEM p FEE 2 00 OWNERAffl &MRS O Q R GUES WATER CLOSET MAIL 2 BATH TUB 200 6 - ADDRESS 5753 GOLDEN ST SHOWER 200 CITY TEMPLE CITY TEL NO. LAVATORY 2 00 ✓} CONTRACTOR PLUMBING SINK 2,00 t ADDRESS 414 So. N. G B RIEL BLVD, DISHWASHER 2 00CITY �gTgL TEL. N SAN GA CLOTHES WASHER 200 STATE LIC LICENSE NO CLASS SWIMMING POOL RECEPTOR 2 00 DISTRICT NO,GROUP �NE PR CES D BY LAWN SPRINKLER SYSTEM 2,00 �rU I WATER HEATER 200 INDUSTRIAL WASTE APPROVAL GAS SYSTEM OUTLETS 2 00 a � INSPECTION RECORD OUTLETS OVER C:) _ U 5 PER SYSTEM' 30Gtfi9�GE55 API EX0571/�G ' O W N Plan check fee See Reverse PLUMBING PERMIT ISSUING FEE S TOTAL FEE J� l APPROVALS DATE IN O S SIGNATURE -Plan check applicant UNDER SLAB WORK Name ROUGH PLUMBING � 74 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 WI TE LAWS REGULATING GAS TEST PLU ALL COUNTY ORDINANCES AND STAI PLUMBING. ' IHEREBY,CERTIFY THAT I AM PROPERLY REGISTERED AND/OR UTILITY CO NOTIFIED y r LICENSED AS REOU IRED BY LOS ANGELES COUNTY AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO RESIDE IN THE ABOVE DES BE RESIDENT ROPERTY, FINAL �L►'t� SIGNATU RE _ OF PERMI TTE PERMIT VALIDATION CK.- M,O. CASH PLAN CHECK VALIDATION CK. M.0. CASH 3_5_2'C'0_;SGV .18 -5 U 3 4.5 0 ,&, J Gv AKER'SCOMPENSATIONDECLARATION• DPW 9189 APPLICATION FOR PLUMBING PERMIT 76A667A Thereby 76A667 affirm Ghat I have a certificate of consent to self insure, or'4 certificate'o%Worker's Compensation Insurance, or a certified copy t"mo'ff(Sec 3800 Lab IC ; COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV. Policy No Company J 1:1 ,,r• Certified copy is hereby furnished FOR APPLICANT TO FILL IN(PRINT OR TYPE) - BUILDING ElCertified copy is filed with the county budding inspection ADDRESS ��f� department �1 NUMBER FIXTURE OR ITEM ® FEE LOCALITY —rt�/ Date Applicant PP WATER CLOSET - � NEAREST CERTIFICATEiOF,EXEMPTION FROM WORKERS' BATH TUB CROSS ST COMPENSATION INSURANCE ASSESSOR MAP BOOK 7 PAGE 0/� 23 PARCEL Of ?— (This section need not be completed if the work involved by the SHOWER per is for one hundred dollars($100)or less) LAVATORY OWNER 641-e— i 1 v V� Q � i T� I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to MAIL SINK ADDRESS become subject to the Workers'Compensation Laws �, -J DISWASHER CITY - TEL NO Dale �~ �� 40. pplicAter ' CLOTHES WASHER NOTICE TO APPLICANT If, making this Certifi too of/ i CONTRACTOR © I� Exemption,you should become subject to the Workers' Comifensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith.comply with such ADDRESS provisions or this permit shall be deemed revoked LAWN SPRINKLER SYSTEM ' LICENSED CONTRACTORS DECLARATION CITY TEL NO I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER (commencing with Section 7000) of Division 3 of the Business and STATE LIC GAS SYSTEM OUTLETS LICENSE NO CLASS Professions Code, and my license is in full force and effect (� OUTLETS OVER DISTRICT NO PBY O 5 PER SYSTEM License Number Lic Class ~ _ 1 FINAL • VALIDATION - W DATE�X.141 20 d Contractor Date (A f I am exempt under Sec FINAL ZBY B&P C for tHis reason Date Plan check fee - , Signature PLUMBING PERMIT ISSUING FEE$ /3 r Eli TOTAL FEE c SINGLE FAMILY Plan check applicant =° � _ .I HOME OWNER-BUILDER DECLARATION Name AD- I hereby affirm that I am exempt from the Contractor's License Law 7 for the following reason (Section 7031 5, Business and Professions Address n '�I ! Code) City Tel No , f ITEMS y e ' I,as owner of the property,will do the work and the structure T At is not intended or offered for sale (Section 7044, Business {{_t i r'tL 2,N-3 ® 00, and Professions Code) , i HEtIK 22. :,{i{J CONSTRUCTION LENDING AGENCY CHANGE! I hereby affirm that there is,a construction lending agency for the r•Citiil�]� performance of the work for which this permit is issued (Sec 3097, Civ C) 1301301-00131 10/16-/913 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 above-mentioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE i WbRKER'S COMPENSATION DECLARATION 67A P1N9189 APPLICATION FOR PLUMBING PERMIT I hereby-affirm tW I have a certificate of consent to self insure, or atherjlificate of 144orker's Compensation Insurance, or a certified f ,copy thefeoflSec 3800 Lab C) COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV. Pobcy No Company ❑ . Certified copy is hereby furnished BUILDING �J �{ FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS 5 / 5 J 6 O IileH cu 0-, .5 r ❑' Certified copy is filed with the county building inspection - , - department NUMBER FIXTURE OR ITEM @ FEE LOCALITY �P� C 1- Date Applicant WATER CLOSET NEAREST a y /F CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST COMPENSATION INSURANCE ASSESSOR p p�7 (This section need not be completed if the work involved by the SHOWER MAP BOOK o O / 1 PAGE 0,23�p PARCEL Q1Z permit is for one hundred dollars($100)or less.) OWNER ogCot '' O fn�' e Z I certify that in the performance of the work for which this permit MAIL J LAVATORY is issued, I shall not employ any person in any manner so as to SINK ADDRESS become subject to the Workers'Compensation Laws r�r/ DISWASHER CITY TEL NO a8S7S O Date — ( &Apphca „' CLOTHES WASHER CONTRACTOR Certific of NOTICE TO APPLICANT If, after making this Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with such ADDRESS provisions or this permit shall be deemed revoked LAWN SPRINKLER SYSTEM -- LICENSED CONTRACTORS DECLARATION CITY ` TEL NO } I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER 0. (commencing with Section 7000) of Division 3 of the Business andSTATE LIC O LICENSE NO CLASS 0 Professions Code,and my license is in,full force and effect GAS SYSTEM OUTLETS U OUTLETS OVER DISTRICT NO PROCESSED BY W- ` 5 PER SYSTEM- O O License Number Lic Class V FINAL DATE VALIDATION LU CL Contractor Date CO) ❑ I am exempt under Sec i BY AL Z B 8P C for this reason Date Plan check fee' , , PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE Q SINGLE FAMILY Plan check applicant HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Law ---, t �_ for the following reason (Section 7031,5, Business and Professions _ Address .5307 +.0■•!t' Code) CI ITEMErur 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 0'AL 20 - 51D and Professions Code) (•HECK CONSTRUCTION LENDING AGENCY - CHANGE 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 7 7 1 t e 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 above-mentioned property for inspection purposes SEE REVERSE'FOR EXPLANATORY LANGUAGE