HomeMy Public PortalAbout6354 GOLDEN WEST AVE_Plumbing__ 7GAW7 G,4ai-6171) +0/75
f APPLICATION FOR PLUMBING PERMIT
s
BUILDING AND SAFETY DIVISION
FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING �+
NUMBER FIXTURE OR ITEM FEE ADDRESS V
WATER CLOSET LOCALITY
NEAREST
BATH TUB 2 ov CROSS ST.
SHOWER OWNER
LAVATORYWAIL 1
QQ ADDRESS 3 SL l
SINK CITY TEL. NO.
DISHWASHER CONTRACTOR {
L
CLOTHES WASHER
ADDRESS
SWIMMING POOL RECEPTOR `
CITY TEL NO.
LAWN SPRINKLER SYSTEM STATE ('
WATER HEATER LICENSE NO. ♦ I CILASS
GAS SYSTEM OUTLETS DISTRICT NO, GROUP ZONE PROCESSED BY g
OUTLETS OVER
6 PER SYSTEM INDUSTRIA` �j
og
TATE
WASTE APPROVAL �y
INSPECTION CORD OVi.
Plan check fee
PLUMBING PERMIT ISSUING FVE $
TOTAL FEE
Plan check applicant
Name [GAS
PPROVALS DATE INSPECTOR'S 91QNATURE
R SLAB WORK
Address H PLUMBING
City Tel. NO. IPING
1 HERESY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATIONENTAND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLYWITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATINGATER HEATER
PLUMBING.
I HERESY C�RTIEYTHAT I AM PROPERLY REGISTERED AND/ORING FIXTURES
LIZENSE0 AS REQUIRED BY LOS ANGELES COUNTY AND STATE OFESTCALIFORNIA OR THAT I AIA THE LEGAL OWNER OF, AHD INTEND TOREBID[ Ui THE ABOVE D SED Rt81D[ TIAL PROPGH Y CO. NOTIFIED
910NA TU RE
OF PERM[ 11 FINAL,
PLAN CHECK VALIDATION CK. M.O. CASH PERMIT VALIDATION M.O. CASH
9 3 res VVV 1 3.5
9 !�s
`78A887,(CE-817) - e/78 .
APPLICATION R PL BI-NC PERMIT ,
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
MAKE GHEGKS PAYABLE TO: c �-
HARVEY T. BRANDT, COUNTY ENGINEER_ . TY�FOR APPLICANT TO FILL IN (PRINT OR TYPE) ONST
NUMBER FIXTU E QR ITEM 0 FEEWATER CLOSET 1.75
MAIL...
BATH TUB 1.75 ADDRESS, E
SHOWER 1.75 CITY TEL. NO. 6-
LAVATORY 1.75 CONTRACTISR
SINK 1.75 ADDRESS
i
DISHWASHER 1.75 CITY TEL N0,
CLOTHES WASHER 1.75 TATE LIC
LICENSE NO- 'CLASS'
SWIMMING POOL RECEPTOR 1.75
DISTRICT NO. GROUP E ESSED V
LAWN SPRINKLER SYSTEM 1.75 `
WATER HEATER 1.75 INJZl1$?RIAL
W OVAL
GAS SYSTEM OUTLETS 1.715 7, INSP$CTION RECORD ' S
OUTLETS OVER W,
6 PER SYSTEM '90 O
L
w
cn
Plan check fee SGS Reverse
PLUMBING PERMIT ISSUING FEE 8 3 DO
TOTAL FEE
APPROVALS DATE iHSP[cTon•e 6h7MATlJ11[
Plan check applicant UNDER SLAB WORK
NarrieMaifA VO4
ROUGH PLUMBING
Address GAS PIPING — -
City Tel. NO. GAS VENT
HOT WATER HEATER
"I HERESY ACKNOWLEDGE THAT I HAVE READ 7}118 APPLICATION
AHD STATE THAT THF ABOVE Ll CORRECT AND AGREE TO CO-MPLY PLUMBING FIXTURE$
WITH ALL COUNTY QRDINANCES AND STATE LAWS RKGULATFNG f
PLUM SING. GAS TEST
I HERESY CERTIFY THAT I Aht EROEERI-Y REGISTERED AMD/OR UTILITY CO. NOTIF-ED-
LICENSED AS REQUI IIED-BY LOS ANGELE0 COUNTY AND }TATE OF
CALIFOKNIA OR THAT I A 7HE GAL OWNER OF, AND INTEND TO
RESIDE IN THE AedV[ RIS R ):a
11TY. INAL
SIGNATU RE
OF PERMITT
RMIT VALIDATION CK. M.O. CASH
PLAN CHECK VALIDTION CK. CASH
J,
ar � ,'3 DEG 10 5 D 4.7 5
W&KERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT �7
I hereby affirm that I have a certlflcate of consent to self 20-0Q28 DPW e/87
Insure, or o certtflcate of Workers' Compensation Insurance, 76AOBIA
or a ceJIfled copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT. O-F PUBLIC WORKS
P❑olIcy NQ7. IM Company Tit � ���_
1
Certlfled copy Is hereby furnished. BUILDING
FOR APPLICANT TO F]LL IN(PRINT OR TYPE)
Certified erttftid copy Is filed with the county building Inapec-
tlon'd partment, Nl1MBER Fi)CUREORITEM FEE
LOC111TY
Date App114ant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION'FROM ROM WORKERS' BATH TUB r CJ S ST. ��
COMPENSATION INSURANCE LS440WER OW1R
(This&*dlon need not be cornpliied if the work Irrvoked by MAIL
the poi. Ilt Is for one hundred dollars (4400)or leu:) LAVATORY ADDRESS
I certify that In the performance of the Hrark for which this ,
permit Is lisued, I shall not employ arty Person In an yy manner
W as to become subject to the Workers Compensation Laws.
DISHWASHER ORS r
Dprte Applicant CLOTHES WASHE=R ADDRESS .
NOTICE TO APPLK-W: If, after mokI% this Cert Ifkafe of SWIMMING POOL RECEPTOR r& N6
Exemptlorr, you should become subject to the Workers'
Compensation provlslorn of the Lobar Code you must forth- LAWN SFRN*_ER S'YST'EM +
27
with comply with sgch provisions or this permit shall br STATE U
deemed revoked. WATER HATER LI(B75E NO. CLAM
LICENSED CONTRACTORS DECLARAT}ON 13
44�_ zq/
DISTRKT NO. PROCESSM 8Y
I hereby affirm that l am I[canted under ppovlslons of Ooopp�t GAS SYSTEM OUTLETS
(commehclhg with Sectlon 7000) of Dbdtlon 3 of the Builness OUTLETSOVER
and Profe*ons Code,and my I[cense Is In full force and effect, S PER SYSTEMFINAL Vt►LIDATION
DATE
yy�� ` Q
Llcerase Numbe Ic. Class.yls.L��
F I NAL
Contractor Date BY
❑ L am exbmpt under Sec.
B.3P.C, for this reasgn
Plan.chggck fee
Z
Date: PLUMBINd PERMLT ISSUING FEE$
Slgrxiturs
TOTAL 1 E5
SINGLE FAMILY Plan check 4ppllcpnt 5
FIOME OWNER-BUILDER DECLARATION Name 11.T.T
I hereby affirm that I am exempt from the Contr6ctor's License
tow for the following•rbason (Section 7Q31.3, �'vslnew and f°s' l ��cJLI
Professions Code): City Tel. N0.❑ I1 I, as oww of the property, will do the work and the
strucTure Is not Intended W offered for igle'(Seciion , TOTAL 65 . 50
41
70 , Business and Professiorts Code).
CONSTRUCTION L$NMNG AGENCY C'Ea, &9.50
1 hereby rffflrm that there Is a conitructl¢n lehding agency for
the performance of the work for which this permit is Neyed � •-1
(Sec. 3097, Civ. C.).
tender's Nome�� 0004-9301' 9/16!?1
Lenders Address 9t 1 1 AM 9=1s
I terrify that I have read this application and stats that the ►
above Information Is correct. I agree to comply with all County
ordinances and State lows regulating Plumbing, and hereby
authorize repro entatives of this County to anter-upon the
olaove-m ed pr9perVor Inspectlon purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
SidnatTre of PerMM" Date