HomeMy Public PortalAbout10134 GREEN ST_Plumbing__ 76 A 667—CE 917 4-eB
APPLICATION FOR PLUMBINGRMIT
• COUNTY OV iOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUII.DING AND SAFETY DIMON 1DiD�nR S ���
JOHN A. LAMBIE. COUNTY ENGINEKR
COLEMAN W. JENKINS. SUPT. OF BUILDING LOC��
FOR APPLICANT TO FILL IN R O TYPECliL ._
NEARM
NUMBER FIXTURE OR ITEM EACH FE H � -/
OW Err_
N7m m
WATER CLOSET 1.50
1[J1II.
BATH TUB 1.50 ADDR£d8
SHOWER 1.50 CITY TEL No.
LAVATORY 1.5 0 COIR mmm o
BII� 1.50 ADDXM20
1
DISHWASHER 1.50 =T 04& j4 TEL NO.
CLOTHES WASHER 1.50 BTAT[ LIC
LICEN[E NO. Z CLASS
B1IIlA�Q6 POOL RECEPTOR 1.50 DIST CT 6ROUr ZONE P Wxx �[D ■Y
LAWN SPRINEI.ER SYSTEM 1.00 0�
WATER HEATER 1.50 IIfDURT1IAT
VIA9TE APPROVAL
GAB SYSTEM OUTLETS 1.5011/7
OUTLETS OVER O
5 PER SYSTEM .30
O
Plan check fee 2,S% of above. See reveme_
PLUMBING PERMIT ISSUING FEE t 2 00
TOTAL FEE
APPROVALS DATE IN/rECTOR'/■IONATURE
Plan check applicant UNDER BLAB WORK
Name ROUGH PLUMBING
Address GAS PIPING
GAS VENT
City. Tel. No.
HOT WATER HEATER
I H[loy ACKNOWI r^ai THAT I E HAVRKAD THIS APP'Ut.ATION
AND STATR THAT TKR A/OVX I/ CORXKCT AND A*RQ TO COM'rLY PLUMBING FIXTURES
WrTHALS COUNTY O/IDINA#=S AND /TAT[ LAW/ GA-8 GATEST
FLUME[No.
I H[R//Y CXPMry THAT I AM rROruLY RKQI9TWFWD AMD/OR UTILITY CO. NOTIFIED
LICVN/m A* RKQUIR>m BY LO/ ANCMLlJ COUNTY D /TAT[ Or
ULIF011N 1A OR THAT I AM [ Li GAL OWTI[R D INTQID TO
RKSID/ IN,TH[AIOV[DK/CR 1�/IDt NTIAL r F NAL
SIGNATUR[ JACK R. ALLEN, SUPERVISIN CH ANICAL GNG'R.
OF PERMITTIK
PERMFF VALIDATION CK. M.O. CASH
PLAN CHECK VALIDATION CK. M.O. CASH
'
v
0 5 fx 8� X18 5 D 6.5q'
1
WORKERS'COMPENSATION DECLARATION 2D-0026 DPW 4197 APPLICATION FOR PLUMBING PERMIT
I hereby, afflrto that I have a certificate of consent to self In- 76A667A
surp;7 a certificate of Workers'Compensation Insuronce,.ora CE 817(REV. 8/86)
cerNl4,ed copy thereof a(Sec. 3800, Lab:C.)
Policy Noi�0104LIPWpany T}./`+({ 'tt S COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Certified copy Is hereby furnished.
- FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
Certified copy is feed with the county building Inspection ADDRESS ! ��
department. NUMBER FIXTURE OR ITEM B FEE LOCALfII
Data Appllca
a4A4n14WATER CLOSET,(TOILET)
CROSS
s
CERTIFICATE OF EXEMPTION FROM BATH TUB ���
EX
COMPENSATION INSURANCE OWNER
(TMs section need not be completod if the work Involved by MAIL
As ptrm'It It for one hundred dollars{$100)or less.) LAVATORY AppRE� (� �'
I certify that In the performance of the work forwhich this per. SINK
mit Is Issued, I-shall-not employ any pamn Ln any manner so CITY ` TEL NO. v'-
as-to become subject to the Workers'Compensation Laws. DISHWASHER r �
COWRACTOR
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of Ex- ADDRESS 1 r
emption,you s'houIM
la become sub ed to the Workers'Compen- LAWN'SPRINKLER
POOL ��
nation proWslona of the Labor Code,you must forthwith comp- LgN SPRINKLER SYSTEM CITY � - 3 _3/)
ly with such provisions or this permit shall be deemed revok- STATE LTC. ��
ed. WATER HE. ] LK 7JSE NO. CLASS
LICENSED CONTRACTORS DLCLARATION DISTRICT NO PROCESSED BY
I hereby affirm that I am licensed under-provisions of Chapter GAS SYSTEM OUTLETS
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Lode, and my license is In full force and ef- 3•PER SYSTEM FINAL VALIDATION >'
foci. t /��� / t ✓C. DATE / oma/ O'
License Number ` Lic. Class 34 U
% FI
L {
Contractor r Dotal— r~ if BY Q W
0
❑ I am exempt under Sec W
B.BP.C. for this reason _ Plan check foe ► a
to.—
ePLUMBING PERMIT ISSUING FEE; ��
Sronotur TOTAL FEE
SINGLE FAMILY heck
HOME OWNER-BUILDER DECLARATION Plan capplicant 5
I hareby affirm that lam exempt from the Contractors License Name
Low Low for the following reason (Section 7031.5, Business and
Professions Code): AddressJ ! LV•7 20. {CJI1
Di, as owner of the property, will do the work and the City Tel. No. 1 1TEhk5
structure Is not intended or offered for sale(Section 70",
Business and Professions Code). ►
TOTAL 20_ 10
CONSTRUCTION LENDINGAGENCY CASH - 20.510
I hereby affirm that there Is a construction lending agency for
'
the performance of the work for which this permit Is Issued .0(1
(Sec. 3097, CI V. C.}.
Lender's Name 1330161-130h 1/ .9/91
Lender's Address 4917 1 AM $-iS
I certify that I have read this application and state that the
bbove Information Incorrect. I agree to comply with all County ►
ordinances and State 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