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HomeMy Public PortalAbout6126 GOLDEN WEST AVE_Plumbing__ 76A667 JCE-817) - 1/75 APPLICATIO , FOR UMBING PERMIT COUNTY OF LOS ANGELES DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING /_ y / ✓� MAKE CHECKS PAYABLE TO: ADDRESS 4 � HARVEY T. BRANDT, COUNTY ENGINEER LOCALITY G FOR APPLICANT TO FILL IN (PRINT OR TYPE) NEAREST CROSS ST. NUMBER FIXTURE OR ITEM @ FEE WATER CLOSET 2.00 OWNERMAIL � ff BATH TUB 2.00 ADDRESS Ave" AV-"q SHOWER 2.00 CITY 7 TEL. NO. LAVATORY 2.00 r? CONTRACTOR AI SINK 2.00 ADDRESS DISHWASHER 2.00 CITY TEL. NO. CLOTHES WASHER 2.00 STATELIC �1 SWIMMING POOL RECEPTOR LICENSE NO. A-VOxl& CLASS IC3(a 2.00 DISTRICT NO.GAF 9UP NE ZPACESS D BY LAWN SPRINKLER SYSTEM 2.00 ©� r-. WATER HEATER 2.00 'INDUSTRIAL WASTE APPROVAL GAS SYSTEM OUTLETS 2.00 INSPECTION RECORD OUTLETS OVER 90 V 5 PER SYSTEM O 8 U W CL N Plan check fee See Reverse PLUMBING PERMIT ISSUING FEE $ TOTAL FEE APPROVALS DATE INSPECTOR'S SIGNATURE Plan check applicant UNDER SLAB WORK Name ROUGH PLUMBING Address GAS PIPING City Tel. No. GAS VENT I HEREBY ACKNOWLEDGE THAT I HAVE READ -THIS APPLICATION HOT WATER HEATER AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY PLUMBING FIXTURES WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING GAS TEST ' PLUMBING. IHEREBY 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 AMITHV LEGAL OWNER OF, AND INTEND TO 1-51 RESIDE IN THE ABOVE DE S C RI BED RESIIDDEEN�T�IAL�!PROPERTY. FINAL m��«"�� �''"`�"'•-"A SIGNATU RE OF PERMITTEE PERMIT VALIDATION CK. PLAN CHECK VALIDATION CK. M.O. CASH � 97t`�'Nffl u 1 0.5 0 WORKERS'COMPENSATION DECLARATION' APPLICATION FOR PLUMBING PERMIT I hereb affirm that I have a certificate of consent to self in- 20-0026 DPW a/87 ,sure,orb certificate of Workers'Compensation Insurance,or a CE 817(REV. 8/86) rertifid;opy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Company n Ce%fied copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING i-\ /� • Certified copy is filed with the count ilding inspection ADDRESS `�1Ja�Se{, V1J�S •t!ve, department. NUMBER FIXTURE OR ITEM @ FEE ` /� Date �V Applicant .3. WATER CLOSET. v LOCALITY NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB 0 CROSS SL ,Q S ��A C� COMPENSATION INSURANCESHOWER OWNER i� ® thT� r` e (This section need not be completed if the work involved by MAIL ` the permit is for one hundred dollars ($100) or less.) LA LAVATORY o ADDRESS I certify that in the performance of the work for which this per- SINK mit is issued,'I shall not employ any person in any manner so CITY eTEL. NO. as to become subject to the Workers'Compensation Laws. ' DISHWASHER 0 CONTRACTOR Date Applicant CLOTHES WASHER ADDRESS W\ NOTICE TO APPLICANT: If, after making this Certificate of Ex- emption,you should become subject to the Workers'Compen- q` � ,Z sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM CITY LbP TEL. NO. J SIG ly with such provisions or this permit shall be deemed revok- STATE y�j' �'�'y LIC. C ed. WATER HEATER b 01) LICENSE NO. ` A — ` CLASS LICENSED CONTRACTORS DECLARATION ,DIS7.RICT NO� OCESSED BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS `Fs/� 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL ^1 V LIDATION fect. License Number �� l1 Lic. Closs C v ' DATE 0 FINAL U Contractor �"AM V� Date BY O I am exempt under Sec. U LU B.BP.C. for this reason tL Plan check fee ca Date: PLUMBING.PERMIT ISSUING FEE$ Signature TOTAL FEE .:915 0 SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Plan check applicant p 1 hereby affirm that I am exempt from the Contractor's License Name n Law for the following reason (Section 7031.5, Business and ACCT.V Professions Code): Address sol i 2.50 ❑ I, as owner of the property, will do the'work and the City Tel. No. 1 ITEMS structure is not intended or offered for sale(Section 7044, 9y ,q 1 Business and Professions Code). ' TOTAL .' 2.50 CONSTRUCTION LENDING AGENCY1:nGK 112o11 I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued CHANGE ,Ulf (Sec. 3097, Civ. C.). j Lender's Name DOW-0001 9/27/8? r-4 1 Ate its e 09 Lender's Address +.5 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 Igws regulating Plumbing, and hereby authorize presentatives of this County_ to enter upon the abov a Toned property for i spection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE nature of Permittee Date