HomeMy Public PortalAbout5642 GRACEWOOD AVE_Plumbing__ DEPARTMENT OF COUNTY ENGINEER PLUMBING
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
OC COUNTY OF LOS ANGELES BUILDING
WILLIAM J. FOX, COUNTY ENGINEER ADDRESS
Pq
FOR APPLICANT TO FILL IN LOCALITY
BUILDING - NEAREST
ADDRESS C*, i-. - :s(4 CROSS ST.
DISTRICT NO. GROUP ZONE PERMIT NO.
LOCALITY
NEAREST
CROSS ST. RECEIVED BY Ready for Inspection DATE ISSUED
OWNER
MAIL INDUSTRIAL
ADDRESS WASTE APPROVAL
CITY TEL.NO. INSPECTION RECORD
PLUMBER al-lc—
ADDRESS
CITY TEL.NO. O
D STATE
LICENSE N0. COUNT) J
PERMIT FEES z
NUMBER TYPE OF FIXTURE OR ITEM FEE 9
% ir WATER CLOSET(TOILET) @ 0.80 $ —
O
BATH TUB @ 0.80
SHOWER @ 0.80
LAVATORY (WASH BASIN) @ 0 80
KITCHEN SINK @ 0.80
LAUNDRY TUB OR TRAY @ 0.80
SLOP SINK @ 0.80
FLOORSINK @ 080
FLOOR DRAIN @ 0.80
DISHWASHER @ 0.80
DRINKING FOUNTAIN @ 0.80
URINAL @ 0.80
GAS SYSTEM____- ---.-_OUTLETS @ 1.00
WATER HEATER @ 1.00
MISCELLANEOUS
APPROVALS
DATE INSPECTOR'S SIGNATURE
UNDER SLAB WORK ' f ir
PERMIT $ 1 00 ROUGH PLUMBING t�
TOTAL FEE GAS PIPING
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI. GAS VENT
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE HOT WATER HEATER47
I`
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS
REGULATING PLUMBING. PLUMBING FIXTURES
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY GAS TEST
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. UTILITY CO.NOTIFIED
SIGNATURE
OF PERMITTEE.. _ = ................_....................................
FINAL
76A667 DBS 17 1/53
WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby, affirm that I have a certificate of consent to self in- 76A66�A PW 4/90 r
sure, or a certificate of Workers'Compensation Insurance,or a
certified copy thereof (Sec. 3800, Lab. C.) �--`--`�
COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No. Company
Certified copy is hereby furnished. BUILDING
FOR APPLICANT TO FILL IN(PRINT OR TYPE) �
Certified copy is filed with the county building inspection ADDRESS
department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
WATER CLOSET(TOILET)
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 ($100)or less.) LAVATORY ADDRESS
I certify that in the performance of the work for which this per- SINK
mit is issued, I shall not employ any person in any manner so CITY TEL. NO.
as to become subject to the Workers' Compensation Laws. DISHWASHER
CONTRACTOR
Date. Applicant CLOTHES WASHER
ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR
emption,you should become subject to the Workers'Compen- CITY TEL. NO.
sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEMS
ly with such provisions or this permit shall be deemed revok- STATE LIC.
ed. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter f GAS SYSTEM OUTLETS
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER , a
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDATION O
fect. HOSE BIB DATE 0
License Number Lic. Class W
J
FINAL ly
Contractor Date BYJOPcc
}
I am exempt under Sec. w` Q
IX. ` O
B.&P.C. for this reason Plan check fee010. #y� �y a
Date: PLUMBING PERMIT ISSUING FEE$ ,.�/ ,fig- p W
Signature sib
TOTAL FEE �
SINGLE FAMILY tr
HOME OWNER-BUILDER DECLARATION Plan check applicant
I hereby affirm that I am exempt from the Contractor's License Name
Law for the following reason (Section 7031.5, Business andf ..
Professions Code): Address
0 I, as owner of the property, will do the work and the City Tel. No.
structure is not intended or offered for sale(Section 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 ,
above information is correct. I agree to comply with all County
ordinances arnd.&tote laws regulating Plumbing, and hereby
authorize,--representatives of this County to enter upon the
above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
-..Signature of Permittee Date