HomeMy Public PortalAbout5037 KAUFFMAN AVE_Plumbing__ 76A66 d - 1
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APPLOCATHON -FOR PLUMBDNG pERMOT
COUNTY.OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL
N(PRINT.OR TYPE) BUILDING
ADDRESS
NUMBER FIXTURE OR ITEM @ �F7EE
3 ,LOCALITY -5
WATER CLOSET
NEAREST
BATHTUB CROSS ST. 19
RE-
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SHOWER. OWNER 6,/.z,,T
MAIL
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LAVATORY 'ADDRESS /►/TI.�T . JO��(,
SINK CITY �s_,r TEL.NO.a*,5'#2_y-
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S
DISHWASHER CONTRACTOR
CLOTHES WASHER ADDRESS
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SWIMMING POOL RECEPTOR
CITYTEL.NO --
LAWN SPRINKLER SYSTEM
.
STATE LIC
WATER HEATER LICENSE NO.,2. , q I CLASS
GAS SYSTEM OUTLETS APPROVALS DATE INSPECTOR'S SIGNATURE
OUTLETS OVER UNDER SLAB WORK
5 PER SYSTEM ROUGH PLUMBING
GAS PIPING
GAS VENT
.CY
HOT WATER HEATER
PLUMBING FIXTURES
GAS TEST
Plan Check fee UTILITY CO.NOTIFIED g
PLUMBING PERMIT ISSUING FEE$
TOTAL FEE FINAL
Z'7
Plan check applicant PLAN CHECK VALIDATION
Name
Address
City Tel.No.
I HEREBY.ACKNOWLEDGE THAT IHAVE READ THIS APPLICATION AND STATE -
THAT THE ABOVE IS CORRECT AND AGREE TO.COMPLY WITH ALL COUNTY ORDINANCES
�. AND STATE LAWS REGULATING PLUMBING. PERMIT VALIDATION , n A
I HEREBY CERTIFY THAT I AM PROPERLY REG) TE 'ND/OR LICENSED AS " Y
REQUIRED BY LOS ANGELESRCOUNTY AD STATE OF CA IFORNIA ORYTHAT I AM THE • O O O O a 5
LEGAL OWNER OF.AND IN TE D TO IDE IN THE ABOV SCRIBED RESIDENTIAL
PROPERTY., - 2 0 0 2 5 0
l
SIGNATURE C
OF PERMITTEE 0 0 0 2�J O O C-
DISTRIqT/NO!° ROCESSED BY
2041-78
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INDUSTRIAL
WASTE APPROVAL
WORKERS'COMPENSATION DECLARATION 76A667A
I hereby affirm that I have a certificate of consent to self ce en (2-613
) A P If- U C A T�®N FOR P L 1111 M B N G P E R WII
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab.C.)
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No/M-orb d•rCompany l y"1 &A" A U12-4 C
'Certified copy is hereby furnished. � � �/ FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
® ADDRESS 63 U " ^mdN
Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM O FEE
department. WATER CLOSET LOCALITY
Date ZO-tcA- '4'
/-46 Applicant c �F GL1 Yn -17—e4 ALS NEAREST
BATH TUB ST.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE SHOWER , OWNER SAL1.�4borL
MAIL
(This section need not.be completed if the work involved LAVATORY ADDRESS 5-0-3-7 G 44N '
by the. permit is. for one hundred dollars ($100) or less.) SINK CITY 7��r -PL;E _/7_/ Y � O
TELN0U
I certify that in the performance of the work for which this DISHWASHER cc
permit.is issued, I shall not employ any,person in any manner CONTRACTOR JC q`J.tr LI vnArjg' GOA`` Q
so as to become subject to the Workers' Compensation Laws. CLOTHES WASHERS I? U
ADDRES0V- !$(7� c7-
Date Applicant r�AGlf' GLIr►1AtS-CO✓I20L W
SWIMMING POOL RECEPTOR
NOTICE TO APPLICANT: If,"after making this Certificate of CITY_rN21 vJ' y ` L.NO.Qk 1 3,�•-S-,Lco
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE LIC.
Compensation provisions of the Labor Code, you must forth- LICENSENO. JQ/ 0 ro CLASS Co-ZC--io
with comply with such provisions or this permit shall be WATER HEATER `
deemed revoked.. 1 GAS.SYSTEM OUTLETS ,3 �O DI b1W ESSED BY
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 VALIDA Nness and Professions Code, and,my license is in full force and DATE ,/� ®- �
effect. r
FINAL
License Number d Lic.Class -7-04 BY
C4Ac1F Gu rnA-TG rA
Contractor e-0 Al+-T'20L- . Date
OI am exempt from the licensing requirements as I am a Plan check fee �c% v�`"�
licensed,architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$
acting 'in my professional capacity (Section 7051,'Bus- O p
iness and Professions Code). TOTAL FEE /B (5,a
Lic.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)`.
❑ 1, as owner of the property, am exclusively contracting
with licensed contractors to construct the project
(Section 7044,Business and Professions Code)'. 2 4 8 5 A
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency o.0 0 0 0 5
for the performance of the work for which this permit is 2-0 0 10,00
issued(Sec. 3097,Civ.C.).
Lender's Name 00010,005
Lender's Address
1 0,06-8.0
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
authorize representatives of this County to enter upon the
above-mentioned property for inspection purposes.
Signature of Permittee Date