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78AO67 (CE-B -4172 _
• APPLICATION F R PLU 1NG PERMIT
+ COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION _
MAKE CHECKS PAYABLE TO: FNEARFST
ING
ESS !
HARVEY T. DRANDT, COUNTY ENGINEER LITY
FOR APPLICANT TO FILL IN (PRINT OR TYPES ST.
NUMBER FIXTURE OR ITEM p FEE
WATER CLOSET 1,75 OWNER
Al
MAIL
BATH TUB 1,75 ADDRESS
SHOWER 1,75 CITY TEL. NO. - 68
LAVATORY 1,75 CONTRACTOR
SINK 1.75 ADDRESS
DISHWASHER 1.75 CITY Y TEL NO.
CLOTHES WASHER 1.75 STATE' LIC
S
SWIMMING POOL RECEPTOR 1.76 LICENSE NO. CLASS
DISTRICT NO. GROUP NECeES2, BY
LAWN SPRINKLER SYSTEM 1.75
WATER HEATER 1.75 INSTRIAL
WDUAPPROVAL
GAS SYSTEM OUTLETS 1.75 INSPECTION RECORD
OUTLETS OVER 30
5 PER SYSTEM
Plan check fee S•. Reverse
PLUMBING PERMIT ISSUING FEE $ 3 00
TOTAL FEE
APPROVALS DATE INSPECTOR a •IQNA TU R[
Plan check applicant UNDER SLAB WORK
Name ROUGH PLUMBING
Address GAS PIPING
Clty Tel. No. GAS VENT
HOT WATER HEATER
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATC THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY PLUMBING FIXTURES
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING 12
PLUM BI NS. GAS TEST
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 AM THE LEGAL OWNER OF, AND INTEND TO
RESIDE IN THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. FINAL
SIGNATU RE
Or PERMITTEE
PERMIT LIDATION CK. M.O. CASH
PLAN CHECK VALIDATION CK. M.O. CASH /
1.-473 MAY 5 D 4.75- �
D.B.S.-is 25M SETS 12-45 APPLICATION FOR PERMIT
DEPARTMENT OF BUILDING AND SAFETY
COUNTY OF LOS ANGELES PLUMBING
WM. J. FOX. CHIEF ENGINEER
NATURE OF INSTALLATION DISTRICT NO. I GROUP ZONE PERMITS .
ROUGH FIXTURES COMPLETE I �P '! // ✓
HEATER CESSPOOL 1-1 SEPTIC TANK RECEIVED BY READY FOR DATE ISSUED
FIRST INSPECTION
GAS MISCELLANEOUS
APPLICANT FILL IN HEAVILY OUTLINED PORTION ONLY
- JOB _
--NAME ADDRESS - c•... -
ADDRESS _ LOCALITY
J NEAREST
L CITY TEL.No. _ CROSS ST.
COUNTY
CERT.No. EXPIRES C NAME _
MAIL
LOCATION OF SEPTIC TANK, OR CESSPOOL 3 ADDRESS
NORTH 0
CITY TEL.No.
IAM THE LEGAL POSSESSOR OF THE ABOVE LOS
ANGELES COUNTY CERTIFICATE OF QUALIFICATION.
rLUMBER
I AM THE LEGAL OWNER OF THE PROPERTY DESCRIBED
ABOVE. ^• .
f
OWNER
/ CORRECTIONS
L.
i - ✓ c_
SOUTH
DESCRIPTION OF WORK �
BATH TUB FURNACE �}
`I ►ti
HOWER DISHWASHER
0
LAVATORY REFRIGERATOR
KITCHEN SINK WATER SOFTENER
FLOOR SINK AND TRAP
SLOP BINK FLOOR DRAIN '
WASH TRAY URINAL APPROVALS
WATER CLOSET DRINKING FOUNTAIN DATE INSPECTOR'S NAME
WATER HEATER DENTAL LAVATORY ROUGH PLUMBING
METER GAS SODA FOUNTAIN GAS PIPING
OUTL
GAS VENT
(/ CESSPOOL
TOTAL NUMBER OF FIXTURES ,.� J O SEPTIC TANK
L�_CESSPOOI SEPTIC TANK SEWER
S UTILITY CO.NOTIFIED I ��
I TOTAL FEE
FINAL
WORKERS'COMPENSATION DECLARATION reAssrw
I ,!!preby i?fIrtn that I have r certificate of consent to self ct arl (s-$s) APPLICATION FOR PLUMBING PERMIT
insure, tr'r a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sed.3800,Lab.C.)
T COUNTY OF,LOS ANGELES BUILDING AND SAFETY
PoH y Nd.i4d_#0tP9mp4nZW zcNU
Certified copy Is hereby furdishad. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUIL IES �* y� ti[/ �`t Ys
C rtiflad copy it filed with the coup building Inspection NIJk4W_R FIXTURE OR nFM • pg CT �7
ale m — LOCALITY 6.�+ �, Cr7t C[ 4/
Dat Applican WATER CLOSET NE AR T
BATH TUB CROSS ST. o vi g W
CER'T'IFICATE OP)rXEM O PROM WORKERS'
COMPENSATION INSURANCE $HOWER OWNER a � k r
LAVATORY- MAIL
(This aecdm need not be lgted If the work inrotred AD D R ESS/D / Er a 4t x t! /A w{ `
by thD putt is for one hundred doWs ($100) of ION) Si N K CITY 6�r. /t r' TE-L.-NO
9
I certify that in the performance of the work torr which this DISHWASHER2
permit 1. Issued, I ihaH not employ ady person to any manner CONTRA R a
C-1A a / r,�V Jlortf p, 10.
so as to become subject td the Workers'Compensafton Lsws. CLOTHL S WASHER ADDRESS J
Date Appljdani SWIMMING POOL 1+ECEPTORLLl
NOTICE TO APPLICANT:If,after making this Certiticate of CITYF,/ �,�JT4,L.Nd f
Exomptjgh, you should become .subject to the Workers' LAWN SPRINKLER SYST�mSTATE LIG. a
. 16
Compenaatjon provisions of the Labor Code, you must forth- �� CLASS
with Comply -with such proristons or this permit ah4I1 be WATER NEATE; Q� LIOENB NO
deemed revoked GAS SYSTEM OUTLETS DISTRICT NO. PROCESSED BY
LICTNSED CONTRACTORS DECLARATION OUTLETS OVER
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
(Commencing with Section 7000) of Division Tof the Bust, A�
DATE � �� �,�� VALJpAT�ON
nand Professions Code,ind my license Is fn,tuil force and
Professions
-
'� FINAL
(COcense Number 3533 s LLC.caa,. Sy
ontract
I am exempt from the licensing tdqutrements art T am ■ PTari Check fee �j`j ��,GJJrlf
licensed architect or a registaTed professional ontipeer PLUMBING-PERMIT ISSUING FEE
acting in my profesdonai capacity (Section 1051, Bus
loess and PrPfeesions Code). TOTAL, FEE (/ . too
LTC.or Rjak,No. Dote Plan check appltcaht
HOME OWNER-BUILDER DECLARATION P4arne /
I hereby affirm that I am exempt from the Contractor's Address
Lipepae Low for the foBoV tag reason (Section.7031,5, 1)uai- Cky TN.No,
nets and Profeasivtu Code):
I, as ovrner of the property, am exclusively contrrtting
with licensed cohtracto" to Codstruct the .project 2 4 0 2 b A
(Section 7044, Business a4d Professionp Code).
#'eeooe5
CONSTRUCTION LENDING AGENCY
I• hereby affirm that there.V ■ construction'lending agency z ° '0 1 Q 0 0
for the performance of the work for which this permit is
isYued(Sec. 3097,Civ.C.). . / oto o 1 Q 0 0 5
Lenders Name
Lender's wddrW l�d►tA 0`210-8 1
I certify that I have reed this hpplication and state that the
above information is correct.I agree to comply with all County
ordinances and State laws reguiatLng_piumbing, and hereby SEE REVERSE FOR EXPLANAT4DRY LANGUAGE
authorise representatives of this County to. enter upon the ti
above mentioned properly for inspection purposes.
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