HomeMy Public PortalAbout6213 GOLDEN WEST AVE_Plumbing__ COUNTY OF LOS ANGELES APPLICATION FOR PERMIT
Department of County Engineer
DIVISION OF BUILDING & SAFETY
WILLIAM J. FOX, County Engineer
FOR APPLICANT TO FILL IN DISTRICT O. GROUP I ZONE PERMIT NEI.
PLUMBER REC 1. ED Y READY FOR DATE ISSUED
FIRST INSPECTI N —.�/ —;
ADDRESS Ce
BUILDING
CITY TEL. No. ADDRESS r
COUNTY LOCAL IT*11-o;'�
LICENSE NO. EXPIRESp�
NEAREST P
PERMIT FEES cRoss s . P
NUMBER TYPE OF FIXTURE OR ITEM FEE OWNER
MAIL /t N
—. WATER CLOSET(TOILET) 0 0.50 $ ADDF3ESS (�
BATH TUB @ 0.50 CITYh EL. NO.
'��-- @ 0.50
1 HEREBY ACLEDGE THAT 1 HAVE READ THIS
LAVATORY (WASH BASIN) @ 0.50 APPLICATION AlATE THAT THE ABOVE 19 CORRECT
AND AGREE TO 0 PLY WITH ALL COUNTY ORDINANCES
KITCHEN SINK ® 0.50 AND STATE LAW EGULATING PLUMBING.
I CERTIFY THAT I POSSESS THE ABOVE VALID LOS
LAUNDRY TUB OR TRAY @ 0.50 ANGELES COUNTY LICENSE, OR I M THE LEGAL OWNER
OF THE RESIDENTIAL PRO E ESCRISED ABOVE.
GAS SYSTEM OUTLETS Q 0.50
SIGNATURE OF
WATER HEATER @ 0.50 PERMITTEE
AIM
SLOP SINK @ 0.50 INSPECTION ORD
FLOOR SINK @ 0.50
FLOOR DRAIN @ 0.50
d � rid
DISHWASHER @ 0.50
DRINKING FOUNTAIN @ 0.50
URINAL @ 0.50 Q
HOUSE SEWER Q 0.50 9 tip _Z
MISCELLANEOUS ' f a
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APPROVALS
DATE/ fINSPECTOR'S NAME
• ROUGH PLUMBING
GAS PIPING - --:�-
GAS VENT
CESSPOOL @ 1.00 CESSPOOL /
SEPTIC TANK: SEPTIC TANK
DRAIN ( ) PIT ( ) @ 1.00 SEWER ��ee
PERMIT 1.00 GAS TEST
UTILITY CO.NOTIFIED
TOTAL FEE
FINAL
7GA667 DBS#17 6-52
WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self 76A667A v
insure, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81)
or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
❑ Certified copy is hereby furnished. r
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ` "s'J 7•
❑ Certified copy is filed with the county building inspec- ADDRESS
NUMBER FIXTURE OR ITEM @ FEE
tion department. LOCALITY f
Date Applicant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE OWNER x
SHOWER
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESSs - ti-
1 certify that in the performance of the work for which this _
TE ,
permit is issued, I shall not employ any person in any manner SINK CITY
so as to become subject to the Workers'Compensation Laws. DISHWASHER
M r CONTRACT
a
Date '{Applicant f s,a CLOTHES WASHER w d
NOTICE TO APPLICANT: If, after mdk ng this Certificate of ADDRESS ,
r
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
;. r
CIT C. 7LY ✓, TE 4 f46 a� A
Compensation provisions of the Labor Code, you must forth-
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE �; �� m LIC. �m
deemed revoked. WATER HEATER LICENSE NO. „o CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER W,
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDATION 0
DATE W
License Num beP A ! Lic. Cllassl w' .r
NAL
C'an actor
j w`df Dater L`"s/ B �
I am exempt under Sec.
B.BP.C. for this reason Q
Plan check fee N1111111. �
Date: PLUMBING PERMIT ISSUING FEE$
0-1
Signature 2
LLJ
l TOTAL FEE
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
h I hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business and
Professions Code): City Tel. No.
❑ I, a§ owner of the property, will do the work and the
structure is not intended or offered for sale (Section , �. • c.
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
it 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
f ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above mentioned pro erty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date