HomeMy Public PortalAbout10150 LA ROSA DR_Plumbing__ ]fi M66]C ICE-817BI 9h6 _� •/ I / / n 1 7 //
APPLICATION FOR PLUBING PERMIT
BUILDING AND SAFETY DIVISION
FOR APPLICANT TO FILL IN [PRINT OR TY PEI BUILDING
NUMBER FIXTURE OR ITEM @ FEE ADDRESS
WATER CLOSET LOCALITY L— /J
BATH TUB NEAREST
CROSS ST.
SHOWER OWNER
LAVATORYMAIL
ADDRESS
SINK CITY TEL. NO.
DISHWASHER C ONTflFRJi'(Bty��4(1��/'��
CLOTHES WASHER
ADDRE10f2O E.
SWIMMING POOL RECEPTOR
LAWN SPRINKLER SYSTEM CITY MPLE CITY, CA O7v
STATE LIC
WATER HEATER / LICENSE NO. CLASS y
d
DISTRICT NO. GROUP N PR ESS BY
GAS SYSTEM OUTLETS _� V
OUTLETS OVER -
5 PER SYSTEM
INDUSTRIAL U
WASTE APPROVAL y,l
d
INSPECTION RECORD Z
Plan check fee
PLUMBING PERMIT ISSUING FEE S 50 '
TOTAL FEE
Plan check applicant
Name APPROVALS DATE INs aEC Toe's slew Aru R6 '
UNDER SLAB WORK '
Address ROUGH PLUMBING
City Tel. NO. GAS PIPING
I HEREBY ACKNOWLEDGETHATI HAVE READ THIS APPLICATION GAS VENT
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
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 9WNER OF, AND INTEND TO
RESIDE IN THE ABOVE DES BE ESLD TIAL PROPERTY. UTILITY CO. NOTIFIED
SIGNATURE
OF PERMITTEE FINAL
PLAN CHECK VALIDATION CK.. M.O. CASH PERMIT VALIDATION :C . , M.0. CASH
BEADY ®� 111SPECSOPADEG 2 5 D ^ J m e
7.5 0
'
76A$67-CES17 M9 Job #15 C/7— off- 7W C-.7'y .
APPLICATION FOR PLUMBING PERMIT
COUNTY OF LOS ANGELES `
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING Ave.JOHN A. LAMBIE, CouatY Eugin.0r. ADDRESS 101 ROsa IL
CASSATT D. GRIFFIN. Sup t of Building LOCALITY Tempe City
FOR APPLICANT TO FILL IN NEAREST
CROSS ST.
NUMBER FIXTURE OR ITEM
2 WATER CLOSET - OWNER J. R. Fitzgerald
1 MAIL
BATH TUB ADDRESS 21121 Mesarica Rd.
1
SHOWER
crTy Covina TEL. No. ED 2-7925
2 LAVATORY CONTRACTOR Belvedere Plumbing Co.
1
SINE ADDRESS ar ve "
DISHWASHER CITY TEL NO. 1
CONTRACTOR'S STATE
LAUNDRY TUB REGISTRATION NO. 1 6FI COUNTY ❑
1 CLOTHES-WASHER DISTRICTNO. GROUP ZONE PROCESSED BY
1 WATER'HEATER
1 GAS SYSTEM INDUSTRIAL
_ WASTE APPROVAL
INSPECTION RECORD
-2 //1''^ /Co / AN)
•�.�"//J // /yyf� �G //ll� /il
0 $1.00 PER ITEM
10 OR FIXTURE $ 10.00 APPROVALS DATE INSPECT
OR'S SIGNATURE
PERMIT $ 2100 UNDER SLAB WORK /TOTALFEE 12. �� ROUGH.PLUMBING 2d/ l —GAS PIPING
1HEREBY ACKNOWLEDGE THAT'I HAVE READ THIS APPLICATION
ANO STATE THAT.THE ABOVE IS CORRECT AND AGREE TO COMPLY GAS VENT /� AAWITH ALL COUNTY' ORDINANCES AND STATE LAWS REGULATINGHOT WATER.HEATER U.17"I/1 �PLUMBING.1 HEREBY CERTIFY THAT 1 AM'.PROPERLY REGISTERED AND/OR PLUMBING FIXTURES .LICENSED AS REQUIRED BY LOS ANGELES,COUNTY AND STATE OFGAS TEST /CALIFORNIA OR THAT I AM THE LEGAL OWNER OFTHE ABOVE DESCRIBED RESIDE IA PROPERTY. UTILITY CO.NOTIFIED Ir/1 l ISIGNATURE tw /
OFF r� Ad LAV
.1
FINAL r/ ✓l/
®r _ VALIDATION ROBERT A. WOOD,
Cs. N.o. CASH SUPERVISING MECHANICAL ENG'R
LML0 1 1 8 FP2 6 5 D 12 .0 0 M
n WORKERS' COMPENSATION DECLARATION.- APPLICATION FOR PLUMBING PERMIT
In affirm that I ha0e a certificate of consent to self • "20-o02 6 DPW 6/87 ,
nisure, or a certificate of Workers'Compensation Insurdnce, - 76A667A
or Ilt/effrjJ(t({f��iQ�Acopy thereof (Sec. 381
a . C. COUNTY OF LOS ANGELES 'DEPT..OF PUBLIC WORKS LJ
P^olic�NN�L.ompany � �
Certified copy is hereby furnished 1V -
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING o
Certified copy is filed with the county building inspec- ADDRESS
III
hon de artm t. 'NUMBER FIXTURE OR ITEM � FEE
LOCALITY
/•� / WATER CLOSET,
Ddte`� �/APPIi4an� � ' NEAREST � -
CERTIFICATE OF EXEMPTION FROM W KERS' - BATHTUB CROSS ST.
COMPENSATION INSURANCE OWNER
This section need not be completed If the workInvolvedby J SHOWER
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRE
I certify that in the performance of the work for which this -
permit is issued, I shall not employ any person in any manner SINK CITY TEL. N �a
so as to become subject to the Workers Compensation Lows. DISHWASHER
. CONTRACTOR
Date—Applicant - I CLOTHES WASHER /• ' /
NOTICE TO APPLICANT: If,. after making this Certificate of ADDRESS 3•�G(/
Exemption, you should. become subject to the Workers' SWIMMING POOL RECEPTOR-
Compensation provisions of.the Labor Code, you must,forth- LAWN SPRINKLER SYSTEM CITY- TEL, NO.
with comply with such provisions or this„permit shall be STAT LIC.
deemed.revoked
WATER LICE •NO.. x-. CLASS
LICENSED CONTRACTORS DECLARATION DI RICT NO. PROCESSED BY
GAS SYSTEM OUTLETS 0�
I hereby offirm that I am licensed under provisions of Chapter,9 a
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER - '
and Professions Coda, and m license is in force g;(td effect. S PER SYSTEM.. D �/ O
r Ce' FlNAt VALIDATION o
DATE
License Number Lia Class .r1 CJ
FINAL _
Contr D / —9 BY �'(//�V"1/ At..Aa .r
❑ l am.exemp oder Sec 630 1 4,i.ULr W
B.BP.C. for this reason 1 ITEM E''
Plan check fee 3p gp rn
Date: PLUMBINGPERMITISSUING FEE$ /}Q I[I�f1� 43^ ( Z
.
SignatureHECK +PE.UI i .
TOTAL FEE I,� _
Plan check's �)licant - - tdlfhiGE ,1111
SINGLE FAMILY '
HOME OWNER-BUILDER DECLARATION Name -
I.herebyaffirm that I am exempt from the Contractor's License- - .;1lJI?Q-1}fjl]1 101 4I•ifJ
'taw for the following reason (Section.7031.5,'Business and Address' ,
Professions Code): City Tel. No. 3134 _ 1 AN1093111
❑. I, as owner of the property, wiltdo the work and fhe - - '
structure is not intended or offered for sale (Section -
7044, Business and Professions Code). Poo ,
CONSTRUCTION LENDING AGENCY -
I hereby affirm that there is a construction lending agency for
the performance of the work for which tkis 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 informalion is correct. I agree to comply with all County - -
wdinorices and State laws regulating Plumbing„and-hereby
authorize representatives of this County to enter upon the - -
a)!Pfe- entioned'pr rt o Inspection ppurpose_ ^ SEE REVERSE FOR EXPLANATORY LANGUAGE
Sign Lure a er ittee Date - `