HomeMy Public PortalAbout9560 KENNERLY ST_Plumbing__ 76A667-CE817 12159 TEMPLE CITY
APPLICATION FOR PLUMBING PE,RMI`r',
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING �iNDESAFETYIVISION BUILDING
JOHN A L MBI COUNTYGINEER ADDRESS JStoD k NNER
WILLIAM A JENSEN, SUPT�XN
UILDINGLOCALITY
FOR APPLICANT TO L IN NEAREST
CROSS ST.
NUMBER FIXTURE OR ITEM
OWNER
WATER CLOSET E, f, PI M A I✓
ADDRESS F S6 O ){A-�VWE R t 11
BATH TUB
CITY j� — r TEL. NO.,286- 7772
SHOWER ,
LAVATORY CONTRACTOR
2
SINS ADDRESS
DISHWASHER CITY TEL NO.
CONTRACTOR'S STATE El
LAUNDRY TUB REGISTRATIO NO. COUNTY ❑
CLOTHES WASHER DISTRICT NO-
GROUP ZO E OCESSED B
/ WATER HEATER _ r Q 4 L
GAS SYSTEM INDUSTRIAL
' WASTE APPROVAL
INSPECTION RECORD
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@ $1.00 PER ITEM Is /
OR FIXTURE $ APPROVALS J DATE rINSPECTOR S SIGNATURE'S
PERMIT $ 2100 UNDER SLAB WORK ° i ✓� >� ' = �
TOTAL FEE / ROUGH PLUMBING—L� q
GAS PIPING R
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS A PLICATION GAS VENT �� X
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING HOT WATER HEATER Yip'"�y/
�y
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR PLUMBING FIXTURES' Ol...a !�n.
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF GAS TEST n
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIALL���PROPERTY. UTILITY CO NOTIFIED
SIGNATURE ...fir- _ i �+ AI-A �
OF PERMITTEE Y
FINAL i 1`
®r VALIDATION ROBERT A WOOD,
cK. M.O. CASH SUPERVISING MECHANICAL ENG'R
L�:w�9 9 0 0 NAR 2 2 5 0 9.0 r
WORKERS'COMPENSATION DECLARATION 76A667A
I hereby affirm that I have a certificate of consent to self ce e17 (2-e0) APPLICATION FOR PLUMBING PERMIT
insure, or a certificate of Workers'Compensation Insurance,or 7'
a certified copy.thereof(Sec. 3800,Lab.C.) / j
#372256:. State Comp. Iris. Fuad COUNTY OF LOS ANGELES BUILDING AND SAFETY
Po1icy No. Company
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
ADDRESS 960 Kennerly Street
® Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM FEE
epartme t. 1 LOCALITY
1i
Dated-10- 1 Applicant-?v WATER CLOSET NEAREST Temple Cit Q�
1 BATH TUB -3 CROSS ST. � c �'✓ '
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE SHOWER OWNER Earl Pittman
l LAVATORY MAIL
(This section need not be completed if the work involved 3 ADDRESS Same >.
by the permit is for one hundred dollars (5100) or less.) SINK p 0
CITY rr TELealple City . ND286-772 Q
I certify that in the performance of the work for which this DISHWASHER U
permit is issued, I shall not employ any person in any manner CONTRACTOR
jgh=v, Plumbing Service
so as to become subject to the Workers' Compensation Laws. CLOTHES WASHER 0
ADDRESS 912 E. Las Tunas Drive
Date Applicant SWIMMING POOL RECEPTOR U
p
CITY Temple City T TEL. N028 K--3 224 w
NOTICE TO APPLICANT: If, after making this Certificate of 0-
Exemption,
b
Exem tion, you should become subject to the Workers' LAWN SPRINKLER SYSTEM to
p J STATE ry 68 LIC. C- 6 Z
Compensation provisions of the Labor Code, you must forth- LICENSE NO'�79 7 CLASS 3
with comply with such provisions or this permit shall be WATER HEATER
deemed revoked. GAS SYSTEM OUTLETS DISTRICT NO. PROCESSED 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 / VALIDATION
ness and Professions Code, and my license is in full force and 1 ]Yew Shower Para � DATE � ( �
effect.
FINAL
License Number� � Lie.Class F I f
Contractor Date `A) YI 67
_�� 3
I am xempt from the licensing requirements as I am a Plan Check fee 16
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 :9 0 2 9.7 A
License Law for the following reason (Section 7031.5, Busi- City Tel.No.
ness and Professions Code): # o o o o o 5
0 I, as owner of the property, am exclusively contracting 2 0 0 1 9,00
with licensed contractors to construct the project
(Section 7044, Business and Professions Code). 5
0 0 - 19,00
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency 0 7. 1�.0—8 1
for the performance of the work for which this permit is
issued (Sec. 3097,Civ.C.).
Lender's Name
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 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
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