HomeMy Public PortalAbout6244 GOLDEN WEST AVE_Plumbing__ 7"697 APPLICATION FOR PLUM B1NG PERMIT ,1
DBS-17 10-55
DIVISION OF-BUILDING AND SAFETY
Department of County Engineer
County of Los Angeles BUILDING //_ hh
JOHN A LAMBIE, COUNTY ENGINEER ADDRESS (�
CASSATT D GRIFFIN.SUP'T•OF BUILDING
LOCALITY Q I I
FOR APPLICANT TO FILL IN NEAREST-
CROSS ST Wen
OWNER 6 IIG'' `II' JJ 0 rcj 1 I— DISTRICT NO GROUP ZONE I READY FOR INSPECTION
MAIL �7/ �y
ADDRESS
INDUSTRIAL
CITY E 1 [ TEL. NO 4V-7WASTE APPROVAL
PLUMBER a{1i/i HY INSPECTION RECORD
ADDRESS
CITY TEL. NO.
LICENSE NO.
NUMBER. TYPE OF FIXTURE OR ITEM FEE /r 9,d�B (/ per,
WATER CLOSET (TOILET) @ $1 00
BATH TUB @ $1 00 ` r
SHOWER @ $1 00
LAVATORY (WASH BASIN) @ $1 00
KFT�Ff
EW SINK @ $1.00 -
DISHWASHER @ $1.00
LAUNDRY TUB OR TRAY @ $100
CLOTHES WASHER . @ $1.00 '
WATER HEATER @ $1 00 ,
GAS SYSTEM @ $100
APPROVALS
DATE INSPECTOR'S SIGNATURE
UNDER SLAB WORK s /1
PERMIT $ 1 00 ROUGH PLUMBING
a v
GAS PIPING
TOTAL FEE GAS VENT
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY HOT WATER HEATER a
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING. PLUMBING FIXTURES
IHEREBY CERTIFY THAT 1 AM' PROPERLY- REGISTERED AND/OR GAS TEST
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE UTILITY CO.NOTIFIED
DESCRIBED RESIDE ALPROPP
Y.
SIGNATURE
OF PERM ITTEE �� FINAL
JOHN A. LAMBIE. COU///y ENGINEER VALIDATION ROBERT A WOOD, CHIEF PLBG INSPECTOR
UUU CK. N.0. CASH
1 6 2 7 JAN 9 3 6.0 0 �
� r
'V Q�KEP. ;COMPErJSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self 76A667A �.
insure, or'a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81) u
or a certified copy thereof'(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
Certified copy is hereby furnished.
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspec- ADDRESS
tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY f -
WATER CLOSET
Date Applicant NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER
•(This section need not be completed if the work involved by MAIL ^�
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRES
I certify that in the performance of the work for which this
permit is issued, I shall not employ ny person 'n any manner SINK 6 CITY TE 2
so as to b ome subject to the rs'C p nsat. 'IS. DISHWASHER J
CONTRACTOR
Dat Appli a CLOTHES WASHER ADDRESS
NOTIC TO PPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY TEL. NO.
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM 2_—OUTLETS Q
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER OG
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM -1)
FINAL VALIDATION
DATE d
License Number Lic. Class Q
FINA U,
Contractor Date BY
4'
❑ I am exempt under Sec. V
B.BP.C. for this reason LV
Plan check fee ® 0-
Date:
Signature PLUMBING PERMIT ISSUING FEE$ Z
m'
TOTAL FEE
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
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, as owner of the property, will do the work and the
/ structure is not intended or offered for sale (Section ® 5 6 3 9 A
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY # o 0 0 0 0 5
1 hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued I .o o 3 LL 5 0
(Sec. 3097, Civ. C.). _
� � � 3450�
Lender's Name 1 0. 1 4=8 6
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 laws regulating Plumbing, and hereby
a ori a re pre nt iv f this ounty to enter upon the
b ve ent, d o rty or i ection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
ignature of P tee Dat