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BING PE
APPLICATiON FOR PLU
COUNTY OF LOS ANGELES
' DEPARTMENT OF COUNTY 'ENGINEER
I BUILDING AM SAFETY DIVISION BUILDING
JOHN A LAMBIE, COUNTY ENGINEER' ADDRESS
y. COLEMAN W JENKINS SUPT OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN, CEA
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NUMBER FIXTURE OR ITEM EACHI FEE
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WATER CLOSET $125 - / 4�--0
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MAIL '
BATH TUB ADDRESSW
125
7
CITY
y "vim SHOWER 125
LAVATORY 1.25 CONTRACTORS '
ADDRESSI�'
slNx 1.25
CITY
DISHWASHER 125
'STATE
LAUNDRY TUB 125 LICENSE,No/5, ,42�1 CLASS N
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CLOTHES WASHER 125 DISTRICT No OUP k.ZONE PROCESSED BY
WATER HEATER I so s
CD
GAS SYSTEM CUTLETS—
I
WAS TETRIAL
APPROVAL
INDUSso
OUTLETS OVER 5 PER SYSTEM .30 INSPECTION-RECORD' LLJ
CD
Lu
APPROVALS DATE INSPECTOR S SIGNATURE
PERMIT $ 2 0 UNDER SLAB WORK
ROUGH PLUMBING
TOTAL FEE GAS PIPING,
ter+ .-I HERE" ACKNOWLEDGE THAT I HAVE 'READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY GAS VENT
WITHALLI COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING 'HOT WATER HEATER
1. HEREBY CERTIFY~ THAT I,AM PROPERLY REGISTERED AND/OR PLUMBING FIXTURES
LICENSED ASfREQlUIRED BY LOS ANGELES COUNTY, AND STATE OF GAS TEST
CALIFORNIA'OR Tt!�ST,41 AM THE k;�L�OWNER OF,AND INTEND TO
RESIDE IN,THE A13OVE16ESCRIBEDIRESIC)ENTI—ALTP OPERTY UTILITY CO NOTIFIED
-v
SIGNATUR
OF PERM I FINAL
�IbATION JACK R.'-ALLEN
CK Mj 0 CASH SUPERVISING MECHANICAL ENG-R'
WORKERS'COMPENSATION DECLARATION 78A8B7A APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self ce eiz (z-so)
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec 3800,Lab C)
- COUNTY OF LOS ANGE ES � BUILDING AND SAFETY
Policy No Company 1
Certified copy is hereby furnished FOR APPLICANT TO'FILL IN (PRINT OR TYPE) BUILDING /� J'Z
Q
Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM • FEE ADDRESS ! 14le�
department / WATER CLOSET LOCALITY�e
Date' Applicant NEAREST /J
I BATH TUB CROSS ST�J`
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE SHOWER OWNER
����
(This section need not be completed if the work involved , LAVATORY MAIL ADDRESS 2_1 et GL
by the permit is for one hundred dollars ($100) or less.) SINKO
CITY TEL N��/ G 0
I certify that in the performance of the work for which this DISHWASHER
permit is issued, I shall not a ploy any person in any manner CONTRACTOR O O
so as to beco a subject to t W ker ' C sation La CLOTHES WASHER
ADDRESS ()
Dat�PPlic SWIMMING POOL RECEPTOR lL
4.
NOTICE TO APPLICAN , after making this Certificate of CITY TEL NO to
Exemption, you should b come subject to the Workers' LAWN SPRINKLER SYSTEM STATE LIC z
Compensation provisions of the Labor Code, you must forth- LICENSE NO CLASS
with comply with such provisions or this permit shall be WATER HEATER
deemed revoked GAS SYSTEM OUTLETS DISTRICT NO PROCESSED BY
LICENSED CONTRACTORS DECLARATION / OUTLETS OVER
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000)of Division 3 of the Busi- FINAL _ VALIDATION
ness and Professions Code, and my license is in full force and DATE
effect i
FINAL
License Number Lia Class BY
Contractor Date
I am exempt from the licensing requirements as I am a Plan check fee
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$
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 essLicense Law for the following reason (Section 7031 5, Busi- 1CA_,-oty,
Tel No Q 3 8 7 A
ness and Professions Code)
I, as owner of the property, am exclusively contracting # o o o o a 5
with licensed contractors to construct the project
(Section 7044, Business and Professions Code) 2 0 - 2200
CONSTRUCTION LENDING AGENCY _ .o o"o 2 2 0 O v '
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is Q 31,3'—81
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
o dinances and State laws regulating Plumbing, and hereby '
"a thorize representatives of this County to enter pon the
a ove-m bone p ty o inspection purpose
1 Signature of Permittee Date