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HomeMy Public PortalAbout10046 GREEN ST_Plumbing__ 7tW--�I7 12i5Er APPLICATION FOR PLUMBING PERMIT D� � OpF ' GL?JGt$ uNTYQjNxlut >Ma OD W,,am WILLIAM A. J . M'Nl luTT dF d FOR XPYl1CANT TQ PU IN CHOm Qi NUNLISR Furupw oft rrxm OwI� WX=CLOm IIAII. iDD88� RLM Tn CIIT TEL. NO. � SOWER LATATO9T COITHA Ilm iDDK= vy LO[FrKR QTi TEL NO.Ie-* ;Elf* ClOrrBACT0" STATE LLUMAT TUB NEXFOMTIOA AO. ���s D COUNTY CLO'f.'m WAX. D CT NO. GROUP ZONIX F!D DY aas ete�c WAM AFFEOM JXffMd`hOJI W=HD z rr= R�M s APPROVALS DATE[ IIIDPECPOR'a SIGMTUHE PERMIT ; 2 00 MR Sl-&S WOFM TOTAL FEE ROUGH PLUM19ING OAS PIPING 1 CIlI0AL1MQK TFIAT I 9AR 71 DD THII Ar CATIOr. AMD fY71YE THAITT 0®IIU THIE ADM IS A� 1TA7'w Q4QIJ17I�d TO GAS VBr ISM ALL FLU121110. H67 WA7'xR HEATEUt 1 FIIYIIT CKMIIFT THAT II.0AN T RZWSTMM Coulm ARD AID/bp PLUMEINO Fu7T1 CALU L OLICJ3tSIM AS Y�THA�I R THI�WOwmm OF Tm J►ADM OAS 7'x87 tiWD F�7T. UTILITY CO.N&NmED I FINAL w► AMATION ROBERT A. WOOD. X.tl. CAM SUF IUMSING 1!v1SCI icAL ENG'R ' 6 1 ? 6 SEP 8 5 D WORKERS'COMPENSATION DECLARATION 76A667A _ I hereby affirm that I have a certificate of consent to self CE 817 (2-e0) APPLICATION FOR PU M B I N G PERMIT insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.) COUNTY OF LOS ANGE -E BUILDING AND SAFETY Policy No.—Company 0 Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING ` J Certified co NUMBER FIXTURE OR ITEM • FEE ADDRESS copy is filed with the county building inspection department. LOCALITY ;—� e: Date Applicant WATER CLOSET NEAREST0 W``.. .. BATH TUB CROSS ST. r CERTIFICATE OF EXEMPTION FROM WORKERS' h r /'(,�(/M� C_` &-5 ft COMPENSATION INSURANCE SHOWER OWNER //�( MAIL (This section need not be completed if the work involved LAVATORY ADDRESS 6441 e by the permit is for one hundred dollars ($100) or less.) SIN K CITY TE� / U I certify that in the performance of the work for which this DISHWASHER ©� permit is issued, I shall not employ any person in any manner CONTRACTOR A O so too b ubject to the�Wo�ke_rg' Comp at aw� CLOTHES WASHER ADDRES ,,,0? U 1 1V �� U D t Applicant �J\ //,N� �N"J rY W SWIMMING POOL RECEPTOR NOTICE TO APPLICANT: If, after making this Certificate of CITY D ?� L. N Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEMZ STAT z LIC. _ Compensation provisions of the Labor Code, you must forth- LICENS CLASS with comply with such provisions or this permit shall be WATER HEATER deemed revoked. GAS SYSTEM OUTLETS 3 DISTRICT NO. PRO ESSED BY LICENSED CONTRACTORS DECLARATION OUTLETS OVER I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM 9 (commencing with Section 7000)of Division 3 of the Busi- FINAL VALIDATION ness and Professions Code, and my license is in full force and DATE effect. / FINAL �Li/cenns' o AM e�Nufffbetr C Lie.Class BY /Qbrfttaret (eA6 Date D� o I am exempt from the licensing requirements as I am a Plan check fee licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$ acting in my professional capacity (Section 7051, Bus- iness and Professions Code). TOTAL FEE Lie.or Reg.No. Date Plan check applicant HOME OWNER-BUILDER DECLARATION Name J61 /(/ I hereby affirm that I am exempt from the Contractor's Address O� U l ��/L_.' License Law for the following reason (Section 7031.5, Busi- City Tel.N ness and Professions Code): I, as owner of the property, am exclusively contracting @ 2 6 8 A with licensed contractors to construct the project (Section 7044, Business and Professions Code). - CONSTRUCTION LENDING AGENCY 2 • • 1600 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.). • • • 1 6: 0 0 c=r Lender's Name 1 0.1 7-80 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 SEE REVERSE FOR EXPLANATORY LANGUAGE ordin es and State laws regulating Plumbing, and hereby autrize representati s of this County t enter upon the o e-me tioned ty for inspection p oses. CT'OU nature of Per ittee Date