HomeMy Public PortalAbout5841 GOLDEN WEST AVE_Plumbing__ +76A667-CE817 12/59 l
APPLICATION FOR PL MBING PERMIT.
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER /� �
BUILDING AND SAFETY DIVISION BUILDING /.t/,Q-� -
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS
WILLIAM A. JENSEN, SUPT OF.BUILDING
LOCALITY
FOR APPLICANT TO FILL IN NEAREST
CROSS ST.
NUMBER FIXTURE ORATEM
OWNER
WATER CLOSET MAIL
BATH TUB ,O ADDRESS
CITY TEL NO.
SHOWER
LAVATORY CONTRACTOR
SINS ADDRESS
DISHWASHER Z CITY NO. SL6
CONTRACTOR'S- a STATE
LAUNDRY TUB Z REGISTRATION NO. pJ�O COUNTY ❑
CLOTHES WASHER (�, DISTRICT NO, GROUP ZONE OCESSED BY
WATER HEATER
GAS SYSTEM INDUSTRIAL
J. WASTE APPROVAL
INSPECTION RECORD
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ul
/meel 5,`�U/�Jh Y c'v"9,
$1.00 PER ITEM 3 OR IMMURE $ 100 APPROVALS / /DATE INSPECTOR'S SIGNATURE
PERMIT 2 00 UNDER SLAB WORK
ROUGH PLUMBING
TOTAL FEE Q6 -
GAS PIPING /
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION GAS VENT
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING. HOT WATER HEATER
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR PLUMBING FIXTURES
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LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF GAS TEST
CALIFORNIA OR i AM THE LEGAL OWNER OF XHE ABOVE
DESCRIBED RESI11TPROPERTY. UTILITY CO.NOTIFIED
SIGNATURE
OF PERMIT FINAL
®p ATION ROBERT A. WOOD,
cc. U.O, CASH SUPERVISING MECHANIICCAALLJENG'R
: I
P -n�,W�ORKERS�CCIMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of cansenf to self 76A667A
• SnsUre,'or a certificate of Workers' Compensation Insurance, CE 817(REV 10/81)-
or
0/81)•or a cerci i c t r ec 00 La C ) �
Poly P/� , rn � , OU�NTF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is hereby furnished / sn] �/�
1� FOR APPLICANT TO FILL IN'(PRINT OR TYPE) BUILDING
ADDRESS a k) i���
❑ Certified copy is filed with the county building inspec-
tion department NUMBER FIXTURE OR ITEM Q FEE 4�'
• LOCALITY -
WATER CLOSET
Date Applicant NEAREST"' " ^�• L '
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST
COMPENSATION INSURANCEOWNER
SHOWER '
(This section need not be completed.if the work involved by MAIL
the permit is for one hundred dollars ($100)or less.), LAVATORY , ADDRESS "
I certify that in the performance of the work-for which this
permit is issued,'I shall not employ any person in-any manner SINK CITY TEL N
so as to become subject to the Workers'Compensation Laws DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO'APPLICANT If, after making this Certificate of
Exemption, you should become"subject to the Workers' SWIMMING POOL RECEPTOR ,
CITY,---re- TEL N
LAW
Compensation provisions of the Labor Code, you must forth,, N SPRINKLER SYSTEM C 7
with comply with such provisions or this permit shall be ,STATE LIC
deemed revoked WATER HEATER ,i LICENSE NO Cy CLASS
LICENSED CONTRACTORS DECLARATION DrSTRICT NO P ESSED BY
I hereby affirm that jam licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
51 0
(commencing with Section 7000) of Division 3`of the Business OUTLETS OVER
and Professions Code,and my license is in full force and elle 5 PER SYSTEM FINAL VALIDAT N
DATES ' V
License N4exernp(rJder
cClass_ FINAL. O
Contract r BY L"'lL &U
❑ jaec H
B &P C for this reason A Z
_ Plan check fee
Date PLUMBING PERMIT ISSUING FEE$ '56L1 1.3 A
Signature
" TOTAL FEE, d # 0 0 o,o 0 5
SINGLE FAMILY
Plan check applicant + o 0165 0
- '
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License o 0 - 1 65,00
Law for the following reason (Section 7031 5, Business and Address
Professions Code) City Tel No Q 1.2 5'-:-8 cJ
❑ 1, as owner of the property, will do the work and the
structure is not intended or offered foi sale (Sect(on pill. ,.
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 ' pop.above information is correct I agree to comply with all County
ordinances and St lawspreluting Plumbing, and hereby
authoriz repres ntatrvesCounty to enter upon the
above- noon d prop tyinspection purposes'
1-91 � ^ SEE REVERSE FOR,EXPLANATORY LANGUAGE
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Slg atu a of Permittee Date