HomeMy Public PortalAbout10108 LA ROSA DR_Plumbing__ 76A66-A-i,- y
APPLICATION FOR PLUMBING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
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FOR APPLICANT TO FILL IN(PRINT OR TYPE( ADDRESS 1.0108 La Rosa 600 .
NUMBER FIXTURE OR ITEM ® FEE
LOCALITY Temple Cit
WATER CLOSET
NEAREST y/1
BATH TUB ` CROSS ST. L/lL+ pLir-1
SHOWER ,Myam OWNER Hammer
LAVATORY b0 ADDRESS 10108 Rosaf'
SINK CITY Temple City TEL.No. 443-981
DISHWASHER CONTRACTOR Universal- Plumbing
CLOTHES WASHER.. ADDRESS
26 1 :Lee Ave .
SWIMMING POOL RECEPTOR CITY So. El Monte TEL.No. 575-346
LAWN SPRINKLER SYSTEM STATEo
WATER HEATER LICENSE NO. 316018 CLAss C36&C20
GASSYSTEM OUTLETS JLCMBING
PPROVALS DATE INSPECTOR'S SIGNATURE
OUTLETS OVER LAB WORK5 PER SYSTEM LUMBING3NGQ'T V
K
TER HEATER QG FIXTURES 5 I �V��.. {{{t0.
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Plan check feett��rr�� UTILITY CO.NOTIFIED Z
PLUMBING PERMIT ISSUING FEE 8 W
TOTAL FEE FINAL 3
Plan check applicant PLAN CHECK VALIDATION
Name - .y ✓9"(""
Address `A, // 72,F"
City Tel.No. 7%p-0V7'0A- VZ L/n
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE A 4 1 3 I A
THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES
AND STATE LAWS REGULATING PiUMBING. PERMIT VALIDATION 5
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR LICENSED AS
REDD IRED BY LOS ANGELES COUNTY STATE OF CALIFORNIA OR THAT I AM THE p — 2200� 2 q.0 0
•LEGAL OWNER F.AND INTEND TO DE IN THE ABOVE DESCRIBED RESIDENTIAL L C.L.
PROPERTY. ✓ 'J
SIGNATURE (- +'P{ • 2 2 0 0 5
OFPERMITTEE ll -
- _ 0 ` 0279
DI STRINQ. OCESSED BV
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INDUSTRIAL
WASTE APP ROVAL -
WORKf jS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
- I'heiebp firm that I have a certificote.of consent to self 76A667A
insure,-ziii,a certificate of Workers' Compensation Insurance, CE 017(REV. 10/61)
or a•certified copy thereof (Sec.'3800, Lab. C. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING d�
Certified copy is filed with the county building inspe - ADDRESS O
tion department NUMBER FIXTURE OR ITEM C FEE LOCALITY
DaleAppl i4ant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER _
i
(This section need not be completed If the work involved by MAIL
the permit Is for one hundred dollars ($100)or less.) LAVATORY ADDRESS IV0007 �� FOSS Z•
s I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK 4,do-
CITY _ TEL. NO.(/ O
so as to become subject to the Workers Compensation Laws. DISHWASHER ///��� ♦ O
CONTRACTOR b �� �•
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY r- TEL. NO.
with comply with such provisions or this permit shall be STATE2 LIC.
deemed revoked. WATER HEATER LICENSE NO. J CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. ,.! O SSED BY
JQ
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS (O/
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER c
and Professions Code,and my license is in full{arca and effect. 5 PER SYSTEM FINAL ; VALI TION
License Number�377� tic Class
a
�
�j FIN U.
Contractor / //, Date ^� BY l
❑ I am exempt under Sec OF
U
B.SP.C. for this reason W
Plan check fee , d
Date: N
PLUMBING PERMIT ISSUING FEE$ I
Signature _
TOTAL FEE
Plan check 02
plica nt
249,15ASINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name A�aVis e e e 05
1 hereby affirm that I am exempt from the Contractor's License Address d (� I ! - 2a50
Law for the following reason (Section 7031.5, Business and �O
Professions Code): City azlmbl Tel. No. �� •e e - 2 a 5 O,u
❑ I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Sectionpop '0x.02'. 86
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is o construction lending agency 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
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
Abentioped aper • for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
oarm iuee Date