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APPLICATION FOR , PLUMBING - PERMITS � `
COUNTY OF LOS f ANGELES
DEPARTMENT OF COUNTY- ENGINEER' FADDRE a, 'BUILDING AND SAFETY DIVISION / / J
JOHN,A LAMBIE, COUNTY,ENGINEER
i WILLIAM A JENSEN, SUPT OF BUILDING `
FOR APPLICANT TO'FILL IN 1.F�V7" r,+"? �>NUMBER FIXTURE,OR,ITEM EACH FEE'WATER CLOSET $1,25BATH TUB 1.25 �SHOWER 1.25 TEL. NO.
I LAVATORY 1.25 .CONTRACTOR.'*/4 f' i I
SINK 1.25 ADDRESS
1 DISHWASHER.l 1.25 r �,� CITY rI�l�1,,�,f1 � TEL. NO.,E J f
,i
� CONTRACTOR'S STATE
LAUNDRY TUB 1:25' REGISTRATION NO. -%',_�� COUNTY"❑
t CLOTHES WASHER 1.25' DIS RICT NOGROUP ZO PROCESSED BY ;
j WATER HEATER 1.50 7 01 ' h
_ f,7 .=ti
A -GAS SYSTEM OUTLETS, 1.50 ff �� WDUSTRIAL ASTE APPROVAL' 'O
1 OUTLETS OVER 5 PER SYSTEM .30
INSPECTION RECORDLu
1 1 c LL
k F F
' APPROVALS DATE, INSPECTOR'S SIGNATURE
'PERMIT $, 2 00 'UNDER SLAB WORK
ROUGH PLUMBING
TOTAL FEE' GAs PIPING,, r
I HEREBY ACKNOWLEDGE THAT'I HAVE READ .THIS 'AP IC TION GAS VENT
AND•STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY ,
WITH ALL COUNTY ORDINANCES ,AND STATE LAWS REGULATING HOT WATER HEATER
PLUMBING -
I-'HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR PLUMBING
EFIXTI�I'F2E5 ,n f�7.. ,
'•LICNSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ,GAS TEST ` � ✓ �l -�
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF,AND INTEND TO
RESIDE IN,THE ABOVE DESCRIBED•RESIDENTIAL PROPERTY UTILITY CO NOTIFIED
� .
SIGNATURE je�
IGNATURE ,e',(,.•7+:...f a f-yam.,', 3;:. II ,
. OF PERMITTEE
FINAL- ,. •� .�'
VALIDATION = ROBERT a',wooD
CK M O CASH 'SUPERVISING_MECHANICAL ENG'R ".
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WORKER'S COMPENSATION DECLARATION 20-0026 DPW 9/89 76A667A APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self insure, - �
4 or a certificate of Worker's Compensation Insurance, or a certified
copy teof,(Sec 3800 Lab, C.)
I�Ci .-- '_1r1� COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV.
Policy Po Company
❑ Certified,copy is hereby furnished
�yFOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS J � A , LoE/V w�r
LyJ Certified copy is fled with the co y b riding m ection
'department , NUMBER FIXTURE OR ITEM @ FEE LOCALITY -
Date�r " Applicant `WATER CLOSET t NEAREST -
CROSS ST
CERTIFICATE OF EXEMPTION FROM WORKERS' 'BATH TUB
` COMPENSATION INSURANCE ` ASSESSOR
(This section need not be completed if the work involved by the SHOWER MAP BOOK PAGE PARCEL
permit is'for one hundred dollars($100)or less.) LAVATORY - OWNER 5tAops,
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as toMAIL
SINK ADDRESS5�3 Y �itl>t� tr
become subject to the Workers' Compensation Laws
/ DISWASHER CITY- I�/r / 'r T-$J, TEL NO L�qJ -�(��j
Date Applicant
CLOTHES WASHER CONTRACTOR,
NOTICE TO APPLICANT If, after making this Certrficate of •Exemption,you should became 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, S p g }
I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER ! / V Q.
(commencing with Section 7000)of Division 3 of the Business and - STATE c22 p r1 LIC U
GAS SYSTEM OUTLETS LICENSE NO 14 4 _E CLASS
Professions Code,and my license is m full force and effect - Cl,,.-/��//
OUTLETS OVER _ DISTRICT NO PROCESSED BY
r4 �® 5 PER SYSTEM
License Number 6 Lic Class
FINAL
U
DATE VALIDATION
Contractor Date a
AL c N
El I am exempt under Sec BY
JL Z
B&P C for this re A(-C f e s
c� Plan check fee 73131
Date
PLUMBING PERMIT ISSUING FEE$ 075 ' 0O K y f ITEMS
;
Signature
❑ TOTAL FEE j CO5 TOTAL 40 - 6.5
SINGLE FAMILY Plan check applicant CHECKi I ZC I
HOME OWNER-BUILDER DECLARATION Name i �.n't {r�E ,I jl,`
I hereby affirm that I am exempt from the Contractor's License Law CH
POSE
the following reason (Section 7031 5, Business and Professions Address _
Code) , - ' _
City Tel No �Ik�l �—I_IC[0�. 3/71/
❑_, I, as owner of the property, will do the work and the structure
I _ is not intended or offered for sale (Section 7044, Business _
and Professions Code) 89775 I" AM I D 4 c
CONSTRUCTION-LENDING AGENCY C
hereby,affirm that there is a construction lending agency for the
performance of the work for which this permit is issued (Sec 3097, j
Cry C) f
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 St aws regulating Plumbing, and hereby authorize
rep
re ntati es of this g6unty to enter upon the above-mentioned
is
spSEE REVERSE•FOR EXPLANATORY LANGUAGE
j�fJ.ignature of Permittee Date LL