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APPLICATION FOR PLUMBING PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION 77F
JOHN A. LAMBIE. COUNTY ENGINEER WILLIAM A. JENSEN, SUPT OF BUILDING FOR APPLICANT TO FILL IN NUMBER FIXTURE OR ITEM ��'WATER CLOSES BATH TUB
CITY TEL NO.
SHOWER
LAVATORY CONTRACTOR /
slu ADDRESS
DISHWASHER CITY � •(L� 7 3
CONTRACTOR'S _ STATE p
LAUNDRY TUR. REGISTRATION NO. (r� G COONTY ❑
CLOTHES WASHER DISTRICT NO. GROUP ZONE P ESSED BY
WATER HEATER r � _l
GAS SYSTEM INDUSTRIAL —�
WASTE APPROVAL }
INSPECTION RECORD o_
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0 $1.00 PER ITEM '
OR FDOURE $ APPROVALS DATE INSPECTOR'S SIGNATURE
PERMIT $ 2 00 UNDER SLAB WORK
TOTAL FEE ROUGH PLUMBING
GAS PIPING
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ ND TH1E APPLICATION
AND STATE THAT THE ABOVE IS CORRECT TE LAWS E COMPLY GAS VENT
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING. HOT WATER HEATER
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANO/OR PLUMBING FIXTURES
LICENSED AS REQUIRED BY LOS 'ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT 1 AM THE LEGAL OW ER OF THE ABOVE GAS TEST
DESCRIBED RESIDENTIAL PROP ftTY. UTILITY CO. NOTIFIED
SIGNATURE
OF PERM ITTEP //q // A
FINAL � I IY l ��f� �F/��U!/Y/�
ALIDATION ROBERT A. WOOD
cK. M.D. CASH SUPERVISING MECHANICAL ENG'R
Uto 5.4 3 1 : NW 2)4 5 A. 3.0 0
COUNTY OF LOS ANGELES - APPLICATION FOR PERMIT
Dof CD Engineer PLUMBING e
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DIVISIONSION OFF BUILDING & SAFETY
WILLIAM J. FOX, County EnBineor y�P q,
MIT N13.
F9 OPLIC,$NT TR FILL IN D G�J
PLUMBER RE t ED Y READY FOR Op,TE IBB D
FIRST INSPECTION ./� _�y
ADDRESS Y
BUILDING
CITY TEL
Non � ADDRESS
COUNTY LOCALITY Ctl'I+
LICENSE NO. EXPIRES
NEAREST
PERMIT FEES CROSS ST.
NUMBER TYPE OF FIXTURE OR ITEM FEE OWNER iL� �J�O tiI✓ �Q�
MAIL
WATER CLOSET(TOILET) ® O.SO $ k0 ADDRESS
BATH TUB ® 0.50 CITY TEL. No.
SHOWER _ ® O.5❑ O I HEREBY ACKNOWLEDGE THAT i HAVE READ THIS
LAVATORY (WASH BASIN) ® 0.50 'APPLICATION AND STATE THAT THE ABOVE IS CORRECT
_
AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES
KITCHEN SINK ® 0.50 AND STATE LAWS REGULATING PLUMBII O.
I CERTIFY THAT 1 POSSESS THE ABOVE VALID LOS
LAUNDRY TUB OR TRAY ® 0.50 AND ELES COUNTY LICE SE. 0;,.,l AM THE LEGAL^ OWNER
OF THE RESIDENTIAL ❑PERT, DESCRIBED ABOVE.
GAS SYSTEM OUTLETS ® 0.50 Q U
SIGNATURE
WATER HEATER ® 0.50 PERMITTEE E
SLOP BINK 0.50 INSPECTION RECORD
FLOOR SINK 0.50
FLOOR DRAIN Q 0.50
DISHWASHER ® 0.50
DRINKING FOUNTAIN 0.50
URINAL ® p.5p
Q
HOUSE SEWER Q 0.50 Z
MISCELLANEOUS 6
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APPROVALS
DATE INBP CITTOR•9 NAME
ROUGH PLUMBING
GAS PIPING
GAS VENT
CESSPOOL ® 1,00 CESSPOOL
SEPTIC TANK: SEPTIC TANK
DRAIN ( ) PIT ( ) 1.00 SEWER
GA9 TE ST ��y/')L /rCyR GlY� _,IFIO/(Y ITIj�EFJ-
PERMIT LDD
UTILITY CO. NOTIFIED-
TOTAL FEE $
T FINAL
T GAGGi DBS#17 6-52
WORKERS'.that
I hoENSATIONDECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certif icafe of consent to self ,20=0026 DPW 6/87
insure, or 6.certificare'of Workers' Compensation Insurance, 76A667A
or acfer� d copyyry thereof (Sec. 3800,�Lob. Cf�.))y/ COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Polity o. //1/Z Compony �Y1s� � -
❑ Certified copy is hereby furnished. ( ®��
m, FOR APPLICANT TO FILL IN PRINT OR TYPE) BUILDING
Certified copy tfiled with the county building inspec- ADDRESS
tion department,. NUMBER FIXTURE OR ITEM Q FEE LOCALITY -
f'./-4/ ' A11t/9iddAe1_A WATER CLOSET
Date Applicant - NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.' -
COMPENSATION INSURANCE SHOWER OWNER f �,,,
(This section need not be completed If the work involved by MAIL
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS OG !�7
1101"1014-
I certify that in the performance of the work for which this
permit is issued, I shall not employ any persomin any manner SINK CITY C TEL, NO..27,
so as to become subject to the Workers'Compensation Laws. DISHWASHER �
CONTRACTOR /JJ
Date - Applicant 'CLOTHES WASHER / '�•
NOTICE TO APPLICANT: If, after making this Certificate'of ADDRESS
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTORor
Compensation provisions of the Labor Code, you must forth- CITY y� �T iEL NO. '� /�/
LAWN SPRINKLER SYSTEM V
with comply with such provisions or this permit shall be STATE f LIC. C�/sr
deemed revoked. WATER HEATER LICENSE NO. CLASSrY�
LICENSED CONTRACTORS DECLARATION QLYS ICT,glOry PROCESSED BY
I hereby off into that I am licensed under provisions of Chapter 1 GAS SYSTEM t OUTLETS VC/l U/lX
(commencing with Section 7000)u.of Division 3 of the Business OUTLETS OVER �s
and Professions Code,
and my license is in full force and effect. 5 PER SYSTEM FINAL ALIdATION O}.'
License Number
`lLl=J%__3f Lic. Cl as .` L�. ./ DATE
,� �! } FINAL
Contractory�/°s'/�G ���Oate BY O,
❑ 1 am exempt under Seca W
B.BP.C. for this reason
Plan check fee ® 1 N
Date: / \ Z
' PLUMBING PERMIT ISSUING FEE
Signature
TOTAL FEE
SINGLE FAMILY
Plan check applicant
't
HOME OWNER-BUILDER DECLARATION Name ....
(r- s
I hereby affirm that I exempt from the Contractor's License Address
Law for the followingg r reason (Section 7031.5, Business and .,�11� `,lav Cf
Professions Code): City Tel. No. - '"�-r
❑ I, as owner o61he'property, will do the work and the 1 ITEMS
structure is not intended or offered for sale (Section _
7044, Business and Professions Code). ® TWIAL 20 - !TO
CONSTRUCTION LENDING AGENCYr' �;(
I hereby affirm that there is o construction lending yf agency for C•HEC•t� J..
the performance of the work for which this permit is issued - CHAHGE .VIII
(Sec 3097, Civ. C.).
Lender's Name _ 0000-OnOt 8/24/7�1
Lender's Address '7562 I AM10.26
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
authorize representatives-of this County to enter upon the
above-mentioned property for efspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
5,Wturieg of Permittee �r �� Date '
(116AWO/t W U1 _-2n?k-JC__
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