HomeMy Public PortalAbout4840 KAUFFMAN AVE_Plumbing__ 76A667 (CE-817) - 1/75 TEMPLE CITY
APPLICATION FOR PLUMBING PERMIT
COUNTY OF LOS ANGELES Lot #7 Tract #31181
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
MAKE CHECKS PAYABLE TO: BUILDING
ADDRESS I{840 Kauffman Ave,
HARVEY T. BRANDT, COUNTY ENGINEER
Locnury Tem le Cit
A
FOR PPLICANT TO FILL IN (PRINT OR TYPE) NEAREST
CROSS ST. —�
NUMBER FIXTURE OR ITEM @ o FEE
OWNER
WATER CLOSET J
00 QQ A
s Be Weber DevelO ent-
MI L
1 BATH TUB .00 3.00 ADDRESS 26 Tem le City Blvd,
2 SHOWER .00 6 QQ CITY Temple City TEL. NO- 444-0971
LAVATORY ,00 QQ CONTRACTOR Valley Plumbing Co.
3 96i
1 SINK .00 QQ ADDRESS 442 W. Fleetwood Place
DISHWASHER .00 QQ CITY ' Glendora TEL. NO.
-12
1 CLOTHES WASHER .00 QQ STATE LIC
LICENSE NO. 20931 CLASC36;8C42 20
SWIMMING POOL RECEPTOR .00 3
LAWN SPRINKLER SYSTEM
DISTRICT NO.GROUP ZONE ESSED BY
00. h�I
C/ Z _l -�Ji�ei
1 WATER HEATER 00QQ WADSTE A PROVAL CL.
1 GAS SYSTEM OUTLETS .00 3 QQ INSPECTION RECORD V
OUTLETS OVER !��
5 PER SYSTEM .30 93 ! d- O
W
CL
N
Z
Plan check fee See Reverse
PLUMBING PERMIT ISSUING FEE S
TOTAL FEE6 Q APPROVALS DATE INSPECTOR'S SIGNATURE
Plan check applicant UNDER SLAB WORK
Name ROUGH PLUMBING
Address GAS PIPING
City
Tel. NO. GAS VENT
HOT WATER HEATER
I HEREBY ACKNOWLEDGE THAT I HAVE READ •THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY PLUMBING FIXTURES
•WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING a ��
PLUMBING. GAS TEST
I HEREBY CERTIFY THAT IAM PROPERLY REGISTERED AND/OR UTILITY CO. NOTIFIED
a LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO
RESIDE IN THE ABOVE SCRIBED RESIDENTIAL PROPERTY. FINAL
SIGNATURE
OF PERMITTEE
PERMIT VALIDATION CK. M,0: CASH
PLAN CHECK VALIDATION CK. M.O. CASH
�� �,.6'3�`_R ➢ 4 5 9• 46.50698
WORIirm t COMPENSATION DECLARATION CE 8176A667A APPLICATION FOR PLUMBING PERM 0 T
I hereby affirm that I have a certificate of consent to self CE s» (z-ea) IUSd6'
insure, or a certificate of Workers'Compensation Insurance,or
'a cU ifi o y the of(S 3 Lab.C.
COUNTY OF LOS AIIIGELES BUILDING AND SAFETY
olicy No. Company
PP ertified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING << _
ADDRESS
tn Certified copy is filed with the conn build'n inspection NUMBER FIXTURE OR ITEM O FEE '
•,department. WATER CLOSET LOCALITY
Date Applicant NEAREST w
BATH TUB CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE SHOWER OWNER
(This section need not be completed if the work involved LAVATORY MAIL
ADDRESS
by the permit is for one hundred dollars ($100) or less.) �� }
SINK CITY TEL. NO. O
I certify that in the performance of the work for which this. DISHWASHER U
CONTRALTO
permit is issued, [shall not employ any person.in any manner -
so as to become ADDRES
subject to the Workers' Compensation Laws. CLOTHES WASHER
� O'
Date Applicant
SWIMMING POOL RECEPTOR �
NOTICE TO APPLICANT: If, after making this Certificate of �. CITY
TEL W
Exemption, you should become subject to the 'Workers' LAWN SPRINKLER SYSTEM CL
Compensation provisions of the Labor Code, you must forth- STATE LIC. to
with comply with such provisions or this permit shall be WATER HEATER LICENSE NO. CLASS Z
deemed revoked. I DISTRICT NO OCE EDB \
GAS SYSTEM OUTLETS �'� �
LICENSED CONTRACTORS DECLARATION OUTLETS OVER
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000) of Division 3 of the Busi- FINAL VALIDATlO
ness and Professions Code, and my license is in full force and DATE
effect.
FINAL
License Number �� Lie.Class
BY
Contract ate Ci,
�. I am exempt from the licensing requirements as I am a Plan check fee r�
licensed architect or a registered professional engineer
PLUMBING PERMIT ISSUING FEE$
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code).
TOTAL FEE
Lie.or Reg.No. Date Plan check applicant
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's Address
License Law for the following reason (Section.7031.5,,Busi- City Tel.No
.ness and Professions Code):
I; as owner of the property, am exclusively contracting
with licensed contractors to construct the project 920,30 A
(Section 7044, Business and Professions Code).
#'0 o.0oo5
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency .2*--- )600
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.). i0 0 0 1 6 0 0=
' Lender's Name U
Lender's Address .0 9,0'5_8 0
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances and State laws regulating Plumbing, and hereby
uthorize representatives of this County to enter upon the
e-me property for inspection purposms.
S
Signature RTermittee Date