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76A667-CES17-8-58 ,
APPLICATION FOR PLUMBING PERMIT 1
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION ADDRESS 10018 E. Green St.
JOHN A. LRMBIE, County Engineer
CASSATT D. GRIFFIN, Sup't of Building LocAIITY Temple City
FOR APPLICANT TO FILL IN NEAREST
CROSS ST.
NUMBER FIXTURE OR ITEM OWNER H Egigian
2 f WATER CLOSET AMDAIIL DRESS 829 N. l4arengo
1 BATH TUB
1 SHOWER CITY Pasadena TEL. NO.
2 LAVATORY CONTRACTOR Belvedere Plumbing Co.
1 SINK ADDRESS 11900 E. Garvey 4've.
1 DISHWASHER CITY El Monte TEL. NO. GI 89836
1 LAUNDRY TUB CONTRACTOR'S 179568 STATE ❑
REGISTRATION NO. COUNTY
CLOTHES WASHER DIST IjjCT NO. G F-- ON PROCESSE BY
1 WATER HEATER .(/�
Z GAS SYSTEM INDUSTRIAL
WASTE APPROVAL
INSPECTION RECORD
APPROVALS
l2 @ OR FIXTURPER E $
12 .00 DATE INSPECTOR'S SIGNATURE
UNDER 9LAS WORK
PERMIT $ 2100 ROUGH PLUMBING
TOTAL FEE14.00 GAS PIPING
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION GAS VENT .J
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY HOT WATER HEATER T
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING. PLUMBING FIXTURES
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR GAS TEST
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT I AM THE LEGAL NER OF 71'HE ABOVE UTILITY CO.NOT[FI ED u - I-SS
DESCRIBED RESIDENT L PROPERTY.
SIGNATURE
OF PERMITTE FINAL -I TI
ROBERT A.WOOD.
OF � VALIDATION SUPERVISING MECHANICAL ENG'R
CK. Y.O. CASH
? r06424 14 5 A 14.00
•W012f�COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that• I have a certificate of consent to self 7yg667A
rnsure, or a certlfloote of Workers Compensation Ihsurpnce, CE 817(REV. 10/811
A a led copy thereof(Sec. 3800, Labf CA COUNTY OF LOS ANGELES SUIILDING AND SAFETY
Poll o. mpany
❑ Ce ified copy Is hereby furrllahed.
FOR APRJCANT TO19M IN(PRI NT OR TYPE) BUILD NG
✓Certffled Dopy b filed with the county building Inspec- ADDRESS j WIN 5?1
tip d rtment. NUMBER FDcruRE OR PrEM FEE
LOCALITY
Date App l i go n t WATER QE�ET LNEAREST
I 'CIFICATI OF EXEMPTION FROM WORKERS' BATH TUB CROs ST.
COMPENSATION}INSURANCE SHOWER OWNER
(This section need not be completod If tho work fnwwhred by MAIk
the pelmIt is fbr one hundred dell a re(;-100)or tom.) I-&VATOIZY ADDRESS
I certify that In the performon(m of'the work for whlch this
-permit Is Issued, I shall nol employ any�erzon In any manner SINK CITY TEL NO-
so as to become subject to the Workers Cbmpehsatlon Laws. DISHWASHFR
CONTRACTOk
Date- Applicant CLOTHES WASHER
A
NOTICE TO APPLICANT: If, after makln9 this Certificate of PODDRESS
OL
Exemptlon, you should become subject to the Workers' SW4MWCTtrTELCornpensatlon-provlslbns of the W or Code, you must fgrlh- L,AY#WSPRINKLER SYSTEM
with comply-with luch ptovlslonf or this permit shall be STATF LIC
deemed revoked, WATER HEATER D
LICENSED CONTRACTORS DECLARATION D1SFR NO. Y
I hereby affirm that I am licensed under provisions of CfXVt@r 9 GAS SSM OUTLETS
(commehting with Section 7000)of Dlylslon 3 of the Buslnea OUTLETS
and Professions Code,and my Ilcer�Is In full force and effect. 5 SYSTEMI FINAL
DATE VALID��N Q
License Num Ic. class y tSC
FINAL, O
Contractor Dotb BY W
I am exempt under Sec-
W)
B.&P.('. for this reasoh-
Plan check fee
Date PLUMBING PERMIT ISSUING Fa f
$rgrlature
TOTAL FEE Q
Plan shook applicant
SINGLE FAMILY
-NOME OWNER-BUILDER DECLARATION Nome '
1 hereby affirm thrtt I hm exempt from the Compactor's License Address
-Law for the following reason �Sectlon 7031.6, Butlne= and
ProfesslPFu Code): City Tel. No. 5.4 2 3-A
❑ I, as owner of the property, will do the work and the
ltrucrurw-Is not Intended br offered for sate (Section , #'0 0 0'0 0 5
7044, Buslness and Prbfosslonz Code). 2 0 0
CONSTIRUCTION L,ENQINQ AGENCY
I hereby affirm that there is a toristruction lending agency for o;-'Q-3 q 5 Oa
the pecfotrnance of the work for which this penult Is Issued
(Sec. 3097,Civ. C.). • C 9,tO 8,3
Lenders Name
Lender's_6¢drea
I cafl'f( fhdt I hoe road this appllGatloh ar+d state ilial the
above Irrfoemation Is correct.f agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
outhoriztr representatives of this County to enter upon the
abgv ntloned properly spectton pu '
SU REVERSE FOR EXPLANATORY LANGUAGE
Signature cTfPermltto- to