HomeMy Public PortalAbout9527 KENNERLY ST_Plumbing__ 76A667 -CE$ 817 2 62 L^m7BV9�L�p1,Stay CITY
APPLICATION FOR PLUMBING PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER`
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LAMBIE, COUNTY ENGINEER ADDRESS g 7 KP lv Street
WILLIAM A JENSEN, SUP T OF BUILDING LOCALITY Temple City
FOR APPLICANT TO FILL IN NEAREST
CROSS ST.
NUMBER FIXTURE OR ITEM EACH FEE
OWNER Mr. rrs. H. of berg
1 WATER CLOSET $125 1 25
BATH TUB 1 25 ADDRESS 9527 KennerlV Street
SHOWER 1.25 CITY Temple City TEL NO.
1 LAVATORY 125 1 25 CONTRACTOR Midway Plumbing & Supplies
SINK 1.25 1 25 ADDRESS qn4c3l l v B l v d.<<
DISHWASHER 125 CI'T'Y Rosemead TEL. NO.AT 7-0704
CONCTOR'S STATE
LAUNDRY TUB 125 R GIISTRAT ON NO 224389 COUNTY p
CLOTHES WASHER 1 25 DISTRICT NO GROUP ZONE I EROCESSED BY
WATER HEATER 1 50 `^
1 GAS SYSTEM OUTLETS 150 1 50 INDUSTRIAL
WASTE APPROVAL
OUTLETS OVER 5 PER SYSTEM 30 0 INSPECTION RECORD p O
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IC
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a.
APRtij{SVALS RATE INSPECTOR S SIGNATURE
PERMIT $ 2 00 UNDER WORK
25
'' ROUGH PLUMBING
TOTAL FEE
GAS PIPING
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION n JA z;
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY GAS VENT l/ JAz
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING HOT WATER HEATER ,
PLUMBING
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND_/OR PLUMBING FIXTURES
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF GAS TEST
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO
RESIDE IN,THE ABOVE DESCRIBED RESIDENTIAL PROPERTY UTILITY CO NOTIFIED
SIGNATURE n
OF PERMITTE
I1) FINAL
r ALIDATION ROBERT A WOOD
CK M 0 CASH SUPERVISING MECHANICAL ENG R
WORKER'S COMPENSATION DECLARATION 20-0026 DPW 9/89 APPLICATION FOR PLUMBING PERMIT
76A667A -�
I hereby atifrm that 76A667
I have a certificate of consent to self insure, "
or a certificate of Worker's Compensation Insurance, or a certified
copy tnereof(Sec d800'Lab C)'
' COUNTY OF LOS ANGELES DEPT OFPUBLICWORKS DEPT-OF PUBLIC WORKS DIV.
Policy No Company o _
❑ Certified copy is hereby furnished
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING i
Certified copy is filed with the county building inspection ADDRESS
department I NUMBER FIXTURE OR ITEM @ FEE
LOCALITY /
Date Applicant WATER CLOSET , NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST COMPENSATION INSURANCE Z ASSESSORMAP BOOK PAG0-1
EDPARCEL qz
(This section need not be completed if the work involved by the SHOWER
permit is for one hundred dollars($100)or less)_ C2ZLAVATORY OWNE Cir
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so to SINK I MAIL
ADDRESS
bec:;C��
b ct to the Workers' om n tion La C
DISWASHER CITY EL NO
7,3
DatAp CLOTHES'WASHER CONTRACTOR
NOE TO PPLICANT If, after mak is ertUficate of
Exemption,you should become subject to the Worker's' Compensation SWIMMING POOL RECEPTOR ADDRESS
provisions of the Labor Code, you must forthwith comply with such
provisions or this permit shall be deemed revoked LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION CITY TEL NO }
I hereby affirm that I am licensed under provisions of,Chapter 9 WATER HEATER
STATE LIC
(commencing with Section 7000) of Division 3 of the Business and GAS SYSTEM OUTLETS LICENSE NO CLASS V
Professions Code,and my license is in full force and effect
OUTLETS OVER DISTRICT NO, PROCESSED BY cc
5 PER SYSTEM C G Q
License Number Lic ClassFINAL Q
DATE VALIDATION n
Contractor Date — (n
❑ I am exempt under Sec FFIINAL Z
B&P C for this reason
Date
Plan check fee
' ,1
PLUMBING PERMIT ISSUING FEE$
Signature
❑ TOTAL FEE
C
SINGLE FAMILY Plan check applicant
HOME OWNER-BUILDER DECLARATION Name AS_[j,g
I hereby affirm that I am exempt from the Contractor's License Law - - ti 1�
for the following reason (Section 7031 5, Business and Professions Address =ti ISL `_n 1
Code)
City Tel No ITE: ,
I, as owner of the property,will do the work and the structure � �
is not intended or offered for'sale (Section 7044, Business i�:TAL 2_H� 1 u
and Professions Code) , 0HE'
CONSTRUCTION LENDING AGENCY FN
1 i:I JG��Nf3�
I.hereby affirm that there is a construction lending agency for the AW
SE
of the work for which this permit is issued (Sec 3097,
Civ C) _ _rf�n i f
Lender's Name 11909 i. ASI -:c 1
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 I s regulating Plum,ng, and hereby authorize
r,eprese/Its of this County to ter up the above-mentioned
ropspects urpo a SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of P r`mrt ee Date