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76A667 -CE#617 10-62
APPLICATION FOR PLUMBING PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION 7L
BUILDING 612 La Rosa Dr
JOHN A. LAMBIE. COUNTY ENGINEER
WILLIAM A. JENSEN. SUPT OF BUILDING
LOCALITY
Temple (.i :ty
FOR APPLICANT TO FILL IN NEAREST
CROSS ST.
NUMBER FIXTURE OR ITEM EACH FEE
OWNER
WATER CLOSET $1.25 MAIL
BATH TUB 1,25 ADDRESS 9612 La Rosa Dr
SHOWER 1.25 CITY Templp TEL. NO.
LAVATORY 1.25 1 25
CONTRACTOR
1, SINK Bar 1.25 1,25 ADDESS 4 TeleAra:ph Rd
DISHWASHER . - 1.25 CITYPICO Rivera TEL. NO.OX 90900
LAUNDRY TUB . 1.25 EGINSTRAT ON NO. 162364 COUNTY TCTOR'S STATE p
CLOTHES WASHER 1.25 DISTRICT NO. GROUP ZONE P SEED BY
WATER HEATER 1.50 -
150 INDUSTRIAL - a
GAS SYSTEM - OUTLETS WASTE APPROVAL 0
OUTLETS OVER 5 PER SYSTEM .00 ,1 INSPECTION RECORD {.7
7IW ./Y�,..,el')�.L_' 1%:�L �Tir1 AIX:` —0
of I , J`
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'APPROVALS DATE, I.5R.TOA'S S IGNATURE�
PERMIT $ 2 00 UNDER SLAB WORK �, /�r'jn•f'jyJrt N� -_ �f�rTll/
ROUGH PLUMBING
TOTAL FEE GAS PIPING +
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY GAS VENT
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING HOT WATER HEATER
PLUMBING. - '
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR PLUMBING FIXTURES
LICENSED A5 REQUIRED BY LOS ANGELES COUNTY ANO STATE OF GAS TEST
CALIFORNIA OR THAT 1 TXE LEGAL OWNEfl OF.ANO INTE NO TO
RESIDE IN,THE ABOV ES IBED RE$IOENTIAL PROPERTY. UTILITY CO. NOTIFIED
SIGNATURE ,
OF PERMITTE _ FINAL I ?.
VALIDATION ROBERT A.WOOD
c m.o. cnsH SUPERVISING MECHANICAL ENG'R
AIR
15 5 A 7.00
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7GA667 ICE-8171 - I/75 j '_ M p/G (2 I'-rV
APPLICATION FOR PLUMBING PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION )�
MARE CHECKS PAYABLE TO: BUILDIniG 9.�/ �1 /1 ^�,
ADDRESS �7 �i� c5�- /'f" C/
HARVEY T. BRANDT, COUNTY ENGINEER
LOCALITY
f
? FOR APPLICANT TO FILL IN (PRINT OR TYPE) NEAREST
dddt CROSS ST.
NUMBER FIXTURE OR ITEM @ FEE
WATER CLOSET
2.00 OWNER co, �. el I
MAZE ^
BATH TUB 2.00 ADDRESS N '
SHOWER 2.00 CITY TEL NIO.C;�XL6E9
LAVATORY 2.00 CO R
SINK. 2.00 AD IFC920 r .
DISHWASHER 2.00 CITTEMPLE CITY, CA'1 +N O.
CLOTHES WASHER 2.00 STATE Q ry' LIC
LICENSE NO. o�/�(Y / p CLASS
SWIMMING POOL RECEPTOR 2,00
DISTRf CoT NO.GRO�JP /TPNE RO ESSL"EO BY
LAWN SPRINKLER SYSTEM 2,00 /
WATER HEATER INDUSTRIAL
WASTE APPROVAL
GAS SYSTEM OUTLETS 2.00 a
I INSPECTION RECORD O
OUTLETS OVER BO U
5 PER SYSTEM
C
O
U
W
d
y
Z
Plan check fee Sea Reverse
PLUMBING PERMIT ISSUING FEE B
TOTAL FEE
APPROVALS DATE INSPECTOR'S SIGNATURE
Plan check applicant UNDER SLAB WORK
Name -ROUGH PLUMBING
Address GAS PIPING
City Tel. No. GAS VENT
HOT WATER HEATER
I HEREBY ACKNOWLEDGE THAT I HAVE READ .THIS APPLICATION
SAND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY PLUMBING _FIXTURES
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
`PLUMBING. GAS.TEST
I.
HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR UTILITY CO. NOTIFIED
LICENSEDAS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ^
CAL IFORM IA'URTHAT 1 1M ,THE LEGAL OWNE OF, AND INTEND TO
:Rf 510E(IN THEPBDV E'DESCR D IDEN IAI PROPERTY_ f)
`FINAL
SIGNATURE F
op OF.PERMITTEE�'
PERMIT VALIDATION CK. M.O: CASH
A
F. PLA MCFECK VACIDATIONOk. 'M.U. cnsn
.'READY FOR FINAL 6INSPECTnftpA 9 5 ° 7.5 o dv,
.' VJORKERS'.COMPENSATION DECLARATION20-00:26 - APPLICATION FOR PLUMBING PERMIT '
76A667 DPW 4/B7
I hereby afiTm shat I haven certificate of consent to self in .'./6A667A - - � ,.- s
sire,or a certificate of Workers'Compensation.Insurance,or a FE BI71(REV.--8/86) Y --- - - ' •.�+
certified copyahereof (Sec. 3800 Lab C.). " - - -
Pohcy No. Company - _ COUNTY OF'LOS ANGELES _ DEPL OF'PUBLIC, .0, -
Q- Certified copy is hereby furnished '- - -1 - - -
,y .-• FOR'IAPPLICANTTO,FILL IN(PRINT'OR TYPE)' - BUILDING 1
-❑ Certifiecl cc py is filed with the county'building inspection . - - _ ` ADDRESS 1 X Dr -
NUMBER FIXTURE-OR'ITEM LOCALITY
department. 3 - @ ffE
Date �- •.VA lican( ,/,' rWATER CLOSET (TOILET) U C
pF - NEAREST _ � ✓-
r. .I$ „ r BATHTUB ' .. .. ( fC Z .` ,)�U -
CERTIFICATE OF EXEMPTION,FROM WORKERS' CROSS Si.
COMPENSATION INSURANCE ,SHOWER - D WNER V e
(This section need not be completed If the work involved by MAIL -
the'•permlt is for one hundred dollars ($100) or less.)». LAVATOkY ADDRESS LR FL ,)A'
certify thatli 6 the performance of.the`work.for wh ich this per - /y -
I is issued, [.shall not employ an erson in an manner so SINK (� N
P Y yP y [ICIY'�. CITY tYYI �G 'C,T� .T aI(7aGe
as to becomesubject to the Workers'•Compensation Laws. - DISHWASHER - '
s . ' - CONTRACTOR: Q
WhfiC a �,t1 er
Ddle Applicant +' . :CLOTHES WASHER -
ADDRESS
NOTICE TO APPLICANT:,If, after making this_Certificole of Ex- -' s
emption,you should become subject to the Workers'Camper- SWIMMING POOL RECEPTOR
sation rovisions of the Sabor. CITY TEL. NO. .
p Code, you must forthwith comp- LAWN SPRINKLER SYSTEM. - -
ly with sucF provisions orchis^permit shall fie dr.eemed re`vok- - - STATE - LIC. -
ed_: :. - % WATER HEATER ,. - �7. LICENSE NO. CLASS -
LICENSED CONTRACTORS DECLARATION - / . - - / DISTRICT NO. PROCESSED'BY ,
I hereby affirm that 1.am licensed under provisions of Chapter GAS SYSTEM OUTLETSD
9(commencing-with,Section 7000)of Division 3 of the Business - OUTLETS'OVERT
D "
and Code, and my license is in'tull force ef- 5 PER SYSTEM` FINAL VALIDATION _ r
feet DATE _ - '.z
License.Number' ? Lie Class - O
$..,, . v .. FINAL
Coriiracbr -Date` BY O
am exempt under Sec. - y -0 - W
V d
8 8P C forlhis reason _ Plan check fee , Z
Date: PLUMBING PERMIT ISSUING FEES 13 tea{) -
Signanure
..,.r.+ TOTAL HE
SINGLE FAMILY Plan check 8 licant, _ - _
.HOME OWNER-BUILDER DECLARATION Pp -
I hereby affirm that I am exempt from the Contractor's License Name
Law for the following reason (Section 7031'rS,Business'and - -' _ • `. ',- - ., - - a(`�,�eye..• -•
Professions Cade): +' - -, • ' ..Address 1 • ".l i? t'•,1ili
as owner ofthe property, will do the work and the. City. -Tel, No. ITEMS,:
structure ii not intended or offer'ed for sale(Section17044, - -
r1Birsineiss and Professions Code). po
• t. - - p. TOTAL �3v �
'.CONSTRUCTION LENDING AGENCY v •- >•� _ _ l,HGl 'n
I hereby affirm That there is a construction lending agency for
the performance of the work for which this permit is issued
(Se C..3097,'Civ. C.j:
Lender's Name
Lender's Address'
c41 1 AN ?'s4 .
I certify that I have read this application and1state that the - -
above-information is correct. I agree to comply.with all County .
ordinances and.State laws re ulating Plumbing;-and her
' a au ' ' represe Hint' es'of this County,.to. enter upon the
a ove-m 'nitoned pr er rinspection purposes.
SEE'REVERSE FOR EXPLANATORY LANGUAGE
Signature of Perm a Da -