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76A667 (CE-817)-8-71
APPLICATION FOR PLUMBING PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEERD NG
/
BUILDING AND SAFETY DIVISION ADDRESS �` _7 ;e
LOCALITY
FOR APPLICANT TO FILL IN (PRINT OR TYPE) NEAREST
CROSS ST.
NUMBER FIXTURE OR ITEM @ FEE OWNER L�
WATER CLOSET 1.75 MAIL
BATH TUB 1 .75 ADDRESS _
SHOWER 1 .75 CITY
6 �j'. TEL. NO.
NUMBER
1.75 CONTRACTOR r� ���L�2f
SINK 1 .75 ADDRESS D
DISHWASHER 1.75 CITYr TEL. NO.
�f
T y i% _2- moo
CLOTHES WASHER 1.75 STATE /' LIC
LICENSE NO. / CLASS
SWIMMING POOL RECEPTOR 1.75
DISTRICT NO °GR91JP jn� PROCESBY
LAWN SPRINKLER SYSTEM 1.75 C/y'/ .1�/' (j(
WATER HEATER 1.75 INDUSTRIAL
WASTE APPROVAL 96
GAS SYSTEM OUTLETS 1.75 INSPECTION RECORD 0
OUTLETS OVER
5 PER SYSTEM .30
u
L
An
I e
Plan check fee See reverse.
PLUMBING PERMIT ISSUING FEE $ 3 00
TOTAL FEE
APPROVALS DATE INSPECTOR'S SIGNATURE
Plan check applicant UNDER SLAB WORK
Name ROUGH PLUMBING
Address GAS PIPING
City
Tel. NO. GAS VENT
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION HOT WATER HEATER
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY PLUMBING FIXTURES
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING. GAS TEST
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERE AND/OR UTILITY CO. NOTIFIED
LICENSED AS REQUIRED BY LOS ANGELES COUNTY,AN TATE OF
CALIFORNIA-OR THAT I AM THE L L OWNE OF; AN I TEND TO
RESIDE IN THE ABOVE DESCRIB R SIDEN AL PROP RT FINAL
SIGNATURE
OF PERMITTEE
PERMIT VALIDATION cK M.O. -CASH
PLAN CHECK VALIDATION CK. M.O. CASH ° I� Cz
z
WOPKERS' COMPENSATION DECLARATION. i� �(' (� p� n�(� �(� (�� (inn
•20-0026 DPW 4)87 Au P�� `VIt-VTMN.' OR 11. LUI11��5BONG �.EOX1Mff .
.1 ke*reby; a}firm•that I:kave'a certificate of consent to'�self-,in- 76A667A
sure, ora certificate of Workers'Compensation.lnsura ice,ora CE 817,(REV. 8/86)
certified copy thereof (Seca 3800, Lab C.) -
COUPt1TY OF STY DEPT.. OF PUBLIC WORKS
a
Policy No Company
Certified copy,is hereby furnished
FOR'AP.PLICANT TO FILL lN,,(PRINT OR TYPE). '
Certified copy is filed with the county'building'inspection ADIDRESS/ /Z
'-department.- @
" NUMBER FIXTURE OR FEE' -r
- s ITEM LOCALITY r a
NATER CLOSET
Date APPhcant .(TOILET)," " NEAREST.
BATH TUB
f "CROSS ST _
- CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE - OWNER
n
SHOWER
(This sectioneed not be completed-if'the`work involved by MAIC
the perritif Es�forsone„hundred dollars ($100) or.,less') �y LAVATORY ,r� ADDRESS
I;certif that m'th`e performance of the work for wh"ich this:per-
Y' SINK' TEL NO.
mit is issued;'I shall not'employ an`y'person in any,manner so " ale Z�S�O y9
• '0s!to become,subject toxthe Workers' Compensation"Laws. DISHWASHER
CITY
CONTRACTOR
Date Applic6nt ` CLOTHES WASHE, ..?
NOTICE TO APPLICANT: If,-after making thi''s Certificate of Ez- •`
em tion;` ou should become sub'ectto the,Workers'tom en; SWIMMING POOL RECEPTOR
ADDRESS
P Y I P CITY TEL NO u
sahn oprovisi6 of'the Labor Code, you-'must forthwith comp- LAWN'SPRINKLER SYSTEM' -
lyw,itF•sueh'prov signs or.this'pe'rmit shall-be deemed revok- ;;; STATE' ' UC.- .
_ed :a. ., .? =.',WATER HEATER CLASS .
`LICENSE NQ'''
LICENSED CONTRACTORS DECLARATION = s, DISTRICT'NO. ' PROCESSEDBY
GAS SYSTEM
I'her,eby'affirrri.,that I am licensed under provisions of.Chapter OUTLETS
-`s
9(commencin"with Section 7000)of Division 3 of the$usiness ;. OUTLET S"OVER'
•5-.PERSY.STEM`
ns Code, and'm.y"license is in full force and ef- FINAL
p
�D
and Professio
fect l� J
t;
License NO mbeP Lic-Class" U'
,. , VALIDATION
DATE ,�7�
Contractor " ' "R Date
FINAL
BY O,
I am exempt un*der'Sec
s
z
Br&P:C for this reason
Plan check fee
Date:
Signature r•
SUING FE
” PLUMBING PERMIT IS E$ ,
SINGLE FAMILY. `
TOTAL,FEE
Plan check applicant,
' •, .. HOME OWNER-BUILDER;.DECLARATION _
I hereby'gffirm'thaf I arri ex''emptfrom,the;Contractor's License Name
Law•for (he;•following reason (Section 7031.5 Business and t; E
Professions Code) ' t. Address °
I;.as"owner`of.the property, will do the work'and.the City "'. Tel. No.
w
Bus Hess and Profes ostructure is not n
or fdf�red for sale(Sect.an 7044,
-'.
1 ) U Ll
;. -
tONSTRUCTION LENDING,AGENCY' t I
I hereby=offirm that there is a construction,lending agency for' 3-
the performance of;the work for'vJhicfi this permit'is issued - E k�
(Sec:.3097; Civ. C.).''
Lender,'s Name'
€ .
Lender's Address
I certify that L,have read this application and state that the
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
a v -menti d property for inspectionpurposes.
,
SEE-REVERSE FOR EXPLANATORY LANGUAGE,
Si fure of.P.ermittee Date