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76A667—CE 817 APPLICATION FOR PLUMBING PERMI
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUN.DINO �I �L
JOHN A. LAMBIE. COUNTY ENGINEER An U, (Y �
COLEMAN W. JENKINS. SUPT. OF BUILDING. LOCALITY
FOR APPLICANT TO FILL IN (PR NT OR TYPE) NEAREST
CROSS ST.
NUMBER FIXTURE OR ITEM EACH FEE ) _
OWNER �' a
WATER CLOSET 1.50 6IA1L pp
BATH TUB 1.50 ADDRESS J_`
SHOWER 1.50 CITY TEL. NO ('
LAVATORY 1.50 CONTRACT R
SINK 1.50 ADDRESS C r 1
DISHWASHER 1.50 CITY TEL. �,,,�s�
CLOTHES WASHER 1.50 STATE yy ✓ LIC
LICENSE NO. �7 CLASS
SWIMMING POOL RECEPTOR 1.50FMIICT NO. GROUP (.TZ)ONE P CES O BY
LAWN SPRINKLER SYSTEM 2.001T_ A -� / O.
WATER HEATER 1.50ClAL {)
PPROVAL
GAS SYSTEM OUTLETS 1.50INSPECTION RECORD O
OUTLETS OVER .30 V
5 PER SYSTEM -'Z.-lO-Q�" WG.
Z
Plan check fee 250 o[ above. Sere reverse.PLUNIBING PERMIT ISSUING FEE 8 TOTAL, FEEROVALS DATE INSPECTOR'S SIGNATURE
Plan check applicant LAB WORKName LUMBING
Address GAS PIPING
GAS VENT
City Tei. No. HOT WATER HEATER
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY PLUMBING FIXTURES
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING GAS TEST
PLUMBING.
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR UTILITY CO. NOTIFIED
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF t
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF,AND INTEND TO 'I
RESIDE IN,THE ABOVE DE RIBED RESIDENTIAL PROPERTY. FINAL /2•'j 3'64' _
SIGNATURE q 4 //J p
OF PERMITTEE 'r"I` ' �� ln,.L. JACK R. ALLEN, SUPERVISING MECHANICgLA
PER111T VALIDATION CK. M.O. CASH
PLAN CHECK VALIDATION CK. M.O. CASH `
LACO; 6 3 ,12 DEC13 5 D 350-
WORKERS''COMPENSATION.DECLARATION ,aassra. -APPLICATION FOR P,LU MBING ..PE'RMIT '
I. hereby affirm 'that I have a certificate of,consent totself CR aii Iz-eol
insure, or'a certificate of Workers'Compensation Insurance,or +
a certified copy thereof.(Sec: 3800,Lab.C.) 'LL
CO.UNTTOFLOS ANGELES BUILDING AND SAFETY
Policy Nolcompany 1 /Y I— K.k oo� (r_..
�• Certified copy is hereby furnished. . FOR.APPLICANT TO'FI LL IN (PRINTjOR TYPE) BUILDING 1 ^q!—, 1�//,,��
.- - ADDRESS 1n.A Y�V j' `r_. ..
Certified copy is filed with t cou t building inspection NUMBER, FIXTURE OR ITEM • „FEE
e e p= COCALITV
WATER CLOSET
DateJ$�.1��S Applicant ' NEAREST - 11 TUB' -
BATH CROSS.ST. V
� f
RA
CERTIFICATE OF EXEMPTION'FROM,WO KERS' • _ _ •'_
COMPENSATION..INSURANCE I SHOWER -. -'� OWNER•
z
y.;. MAIL t }
(This, Section need not.be Completed if tbe'work involved - LAVATORY' Ald' ADDRESS lip O
'by, the permif is for one hundred dollars"(S100) or less.) SINK -
CITY7r /' TEL N044,3
U
�, C� 1 ���!!!
I certify that in the performance of the work for which this DISHWASHERS - •cc'
• .permit is issued, Lshall not employ any person nt any„manner - - CONTRACT I 6 7., 0
so..as to become subject to the Workers' Compensation,Laws CLOTHES WASHER
Date ^ Applicant . _ ADDRES U.
SWIMMING POOL RECEPTOR ADDO TEL N y
NOTICE To APPLICANT If, after making this Certificate bf ,
Exemption you should become subject” to'the Workers - LAWN SPRINKLER SYSTEM° STATELIC: z
Compensation provisions of the.,Labor Code, youmust forth 'LICENSE NOI 116 1 4 CLASS
with comply with such provisions or this, permit shall be WATER.HEATER
deemed revoked. GAS SYSTEM OUTLETS DISTRICT'NO -PR ESSED BY•
LICENSED CONTRACTORS DECLARATION OUTLETS OV.ER _
I hereby affirm that I am licensed under'provisions of Chapter - 5,PE R SYSTEM -
9 (commencing with Section 7000) of Division 3 of the Busi-. FINAL VALIDATIONS
ness and Professions Code, and my'license is in full force and - DATE
.effect.
t �(•�{ _ FINAL
License Nu ` Li c:Class
Co tractor Date I` Q _ 11
I., - - -
I am exempt from he licensing requirements as 1 am.a Plan check fee
licensed
-architect or a registered professional engineer PLUMBING PERMIT ISSUING.FEE$
acting in in my professional capacity' (Section 7051, Bus-
iness
us- -
inessand Professions Code)., TOTAL F,EE - -
Lic:or Reg.No. Date Plan check applicant
HOME OWNER-BUILDER DECLARATION : Name
.._ `i .
11
4 hereby affirm that I am exempt from life Contractordress
's Ad -
License Law for the followinglreason (Section,7031.5. Busi City Telt No.
ness and.Professions Code):' i
El1, as owner of..the property, am.exclusively contracting - - - - •• _ .,�59,9,'b A
with licensed contractors to construct the +project _ - e'q o o'� 5
(Section 7044, Business and,Professions'Code). _
CONSTRUCTION LENDING AGENCY _, . _ ?'� zwa:`5.o
N
I hereby affirm that there is a construction lending agency" ,s .a 2 5 5Q U' -
for the performance.of the work for which this permit is - ..
issue$(Sec. 3097,Civ.C.). .. '/'G, 1.4'_8 3
.Lender's Name - .
Lender's Address. -
I certify,that I have readthisapplication.and state that the
above information is correct.)agree,focomply with all County SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances and State laws. regulating Plumbing,,and hereby -
authorize represematives ,of this County to enter upon the ., .
'abov -i nt'oned property for inspection purposes. '
'Sig ture of Permi ee Dat -