HomeMy Public PortalAbout9010 HERMOSA DR_Plumbing__ 754657,e.�17 5/70
APPLICATION FOR PLUMBING PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DMSION BUILDING
JOHN A. LAMBIE. COUNTY ENGINEER ADDRESS 9010 E e osa ll yr
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COLEMAN W. JENKINS. SUPT. OF BUILDING LOCALITY Temple City pg.. 38 B-2
FOR APPLICANT TO FILL IN(PR NT OR TYPE) NEAREST Rosemead & Encinita
CROSS ST.
NUMBER FIXTURE OR ITEM EACH FEE OWNER
WATER CLOSET .Ise Metro
MAIL Same as above
BATH TUB ,LSq. ADDRESS
SHOWER J,.Sp
CITY TEL. No. 287-3894
LAVATORY + cn CONTRACTOR _
47r
SINK 1.bB- ADDRESS 3141 San Fernando Rd.
DISHWASHER .+,ae cITYLos Angeles TEL. NO. 254-2211
CLOTHES WASHER STATE LIC
LICENSE NO. CLASS
SWIMMING POOL RECEPTOR .L.SP OIBTRICT NO�. GROUP ZONE ROC BBE BY
LAWN SPRINKLER SYSTEM .2.D0 �I QrJ
WATER HEATER h5@ rNDUSTRIAL
3 .00 WASTE APPROVAL
GAS SYSTEM OUTLETS +{d INSPECTION RECORD
OUTLETS OVER
5 PER SYSTEM 30 Z
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Plan check fee 25% of above. See reverse.
PLUMBING PERMIT ISSUING FEE .S 00
TOTAL FEE
APPROVALS DATE INSPECTOR SIGNATURE
Plan check applicant UNDER SLAB WORK
Name Pioneer-Normco Service ROUGH PLUMBING
Address 141 an ernando Rd. GABPIPING
City Los Angeles Tel. No.254-2211 GASVENT
HOT WATER HEATER
1 HEREBY ACKNOWLEDGE THAT I HAVE READ TNI! APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY PLUMBING FIXTURES
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING GAS TEST
PLUMBING.
1 HEREBY CERTIFY THAT 1 AM PROPl RLY REGISTIgEO AND/OR UTILITY CO. NOTIFIED
LICENSED AS REQUIRED BY L09 ANGELES COUNTY ANON TATE OF
ULIFORNIA OR THAT AM TME LEGAL *W I" OF,AND 11 TCND TO
RESIDE IN,THE AS FINAL
g681 EHTI L PROPCRTY. FINAL
SIG PERMITTEE / �G> JACK R. ALLEN, Su PERSING MECHANICAL ENG-R.
PERMIT VALIQATION CK. M.O. CASH.
PLAN CHEC ALIpATION CK. M.0. CASH - � N #
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-WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby0
affirm that I have a certificate of consent to self 20026 DPW 6/87
insure, or a certificate of Workers' C ensation Insuran 76A667A
or a cerlif'fvcop thereyL(�. 38 Lac. C.) _ COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Qay (� 3s� /pan
Certified copy is hereby furnished. -
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with t co y Jding inspec- ADDRESS / C/
'on deportrryeyFj NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Date 1Applica WATER CLOSET NEAREST ('Ci
CERTIFICATE OF EXE TION FROM W+ I RS' BATH TUB CROSS ST.
COMPENSAVON INSURANCE( SHOWER OWNER t ��
(This section need not be completed If the work involved by MAIL
the permit is for one hundred dollars ($I00)or less.) LAVATORY ADDRESS
I certify that in the performance of the work for which this a
permit is issued, 1 shall not employ any person in any manner SINK CITY TEL. NO. 8 1,3O
so as to become subject to the Workers'Compensation Lows. DISHWASHER
CONTRACTOR +
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of S
you Exemption, should become subject to the Workers' SWIMMING POOL RECEPTOR
P Y I CITY TEL. NO.
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM �✓ u'G �� //
with comply with such provisions or this permit shall be STATELIC.
Cp
deemed revoked. WATER HEATER
LICENSE NO. �� CLASS —�
LICENSED CONTRACTORS DECLARATION ^ 'I DISTRICT�od PROCESSED
I hereby affirm that I am licensed under provisions of Chapter 9 f GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full forcend effect. 5 PER SYSTEM FINAL
DATE g'_ 2 _ VALIDATION �yi
License Nu r4 Lic. ClassIV
-
if
FINAL _`•
-� -93
Contracto Date BY 1 IIEML 0
❑ I exempt undA Sec .f'ITA_ s �c
LLF
B.BP.C. for this reason -- l
Plan check fee _�E_r C tI.!. ui
Date: �_ Z.
PLUMBING PERMIT ISSUING FEES T CHANGE
Signature
TOTAL FEE s
Plan check applicant Qlll-QQ11
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name1=- 0"1 1 AM 11:1
—
I hereby affirm that I exempt from the Contractor's License Address
Law for the followingg r reason (Section 7031.5, Business and
Professions Code): City Tel. No.
❑ I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section
7044, Business and Professions Code),
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is o construction lending agency for
the performance of the work for which this permit is issued
(Sec 3097, Civ. C.).
Lender's Nome
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
ordinances and State lows regulating Plumbing, and hereby
ttlotr44e ,,entrot,vesof this Cpoperty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Ittee ate