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APPLICATION
AA aa PLUMBING
-
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS
WILLIAM A. JENSEN, SUPT OF BUILDING
LOCALITY —r
FOR APPLICANT TO FILL IN o CROSS ST. LA ►\ A
NUMBER FIXTURE OR ITEM EACH FEE
OWNER
WATER CLOSET $1.25 • ) - V
MAIL
BATH TUB 1.25 1 S ADDRESS
SHOWER 1.25
CITY TEL. NO.
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LAVATORY 1.25 Q CONTRALTO
SINK 1.25 ADDRESS
DISHWASHER 1.25 C[TY TEL.-N
LAUNDRY TUB 1.25 CONTRACTOR'S STATE
REGISTRATION NO. ` COUNTY ❑
CLOTHES WASHER 1.25 ZS DISTRICT NO. GROUP ZONE PROCESj5VED BY
WATER HEATER 1.50
50 INDUSTRIAL
GAS SYSTEM ' OUTLETS 1. WASTE APPROVAL
OUTLETS.OVER 5 PER SYSTEM .30
Q p INSPECTION RECORD-
IM
'APPROVALS DATE INSPECTOR'S SIGNATURE
PERMIT $ 2 00 UNDER SLAB WORK
ROUGH PLUMBING
TOTAL FEE [� O ` GAS PIPING '
I •HEREBY ACKNOWLEDGE THAT.I HAVE READ THIS APPLICATION' t GASV ENT
AND STATE THAT THE-ABOVE IS.GORRECT,. AND AGREE TO COMPLY -
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING- HOT WATER HEATER
PLUMBING.
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/ORS PLUMBING FIXTURES f
LICENSED AS GAS TEST
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 REST NTIAL,PROPE RTY. UTILITY CO. NOTIFIED / /C]�,,^� -
SIGNATURE �o ®e./o "e"
OF PERMITTEE
FINAL 6" o
ALIDATION ROBERT A. WOOD
cK M.o. CASH SUPERVISING MECHANICAL ENG'R
WORKERS' COMPENSATION DECLARATION �j�o p fl �C A`��O H FOR
P fl Il fl Il 11 p �tlfl� I�2[off Il/1��j'
I hereby affirm that I have o certificate of consent to.self 76A667A trvu L� [rvu IlV I� 11� 1�L�VI1V1! 11G I�LSu�tIIIU u
insure, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81)
or a certified copy thereof (5e. 380 , .) COUNTY OF LOS ANGELES BUILDING AND SAFETY
03 ,3
Polic No. Company
Certified copy is hereby furnished. BUILDING
Certified copy is filed with the county building inspec-
FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS
tion department. NUMBER FIXTURE OR ITEM. @ FEE LOCALITY
Date Applicant WATER.CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE OWNER
(This section need not be completed if the work involved by SHOWER
the permit is for one hundred dollars($100)or less.) LAVATORY MAIL
ADDRESS
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY TEL. NO.
so as to become subject to the Workers Compensation Laws. _
DISHWASHER CONTRALTO
Date?- Applicant AuSS r��e l�r�/7 CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of ADDRESSa&20 etl
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor,Code, you must forth- CITY P , , TEL. NO� _ ZP
LAWN SPRINKLER SYSTEM W
with.comply with such provisions or this permit shall be STATE LIC.
deemed revoked. ` WATER HEATER �0 LICENSE NO CLASS r
LICENSED CONTRACTORS DECLARATION DISTRICT NO. ESSED BY
hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER y
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL / P 9'
VALIDATION
License Number�-a� YS Lic. Class DATE
v129ntr for M ate '1� 7 BY AL --�-� O
� Co ac i=
0 I am exempt under Sec. �
B.&P.C. for this reason
Plan check fee D
Date: PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE
Plan check,applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License =�2 6'1,4.A
Law for the following reason (Section 7031.5, Business and Address
Professions Code): f' o O o.o o 5
City Tel. No.
0 0
'❑ I, as owner of the property, will do the work and the ,2 , . 3.05 0
structure is not intended or offered for sale (Section D 'o 0,0 3 0 5'a u
7044, Business and Professions Code). ,
CONSTRUCTION LENDING AGENCY 0 7. 1 0:—8 4
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 D
above information is correct. 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 T Date