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APPLICATION FOR PLU ING PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
DDRESS
JOHN A. LAMBIE, COUNTY ENGINEER
COLEMAN W. JENKINS. SUPT. OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN NEAREST o
CROSS ST.
NUMBER FIXTURE OR ITEM EACH FEE OWNEP
WATER CLOSET $1.25 MAIL
BATH TUB 1.25 ADDRESS
CITY TEL. NO.
SHOWER 1.25
LAVATORY 1.25 CONTRACTOR _
SINK 1.25 ADDRESS 41
DISHWASHER 1.25 CITY e,STATE LIC
LAUNDRY TU-11 1.25 LICENSE NO. -a CLASS
CLOTHES WASHER Ap1.25 DISTRICT NO GROUP ZODWPRO ES E BY
WATER HEA 1.50
1.50 INDUSTRIAL
GAS SYSTEM OUTLETS WASTE APPROVAL
V
OUTLETS OVER 5 PER SYSTEM .30 INSPECTION RECORD
CD
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W
d
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APPROVALS DATE INSPECTOR'S SIGNATURE
PERMIT $ 2 00 UNDER SLAB WORK
ROUGH PLUMBING
TOTAL FEE GAS PIPING
1 HEREBY,ACKNOWLEDGE THAT I'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.
1 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 OWNER OF,AND IN D TO
RESIDE IN,THE ABOVE DESCRIBED RESIDE A RO PERTY. UTILITY CO. NOTIFIED
SIGNATURE
OF PERM
FINAL
LIDATION JA K R. ALLEN
K. M.0. CASH SUPERVISING MECHANICAL ENG'R.
Li l;�4 'G 91 9 o APR 4 5 D. 3.5 0 r4
WORKERS'COMPENSATION DEe of co PION CE 8176A667A' APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self ce e» (z-aa)
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy * `���
COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No �ZR a y
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING Q
ADDRESS p
Certified copy is filed w the co my building inspection NUMBER FIXTURE OR ITEM • FEE
y�///,� LOCALITY
department. � WATER CLOSET NEAREST '
Dat pplicant
BATH TUB CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS' 171
COMPENSATION INSURANCE SHOWER OWNER MAIL J
(This section need not be completed if the work involved I LAVATORY ADDRESS v`O �/�0�� �/ >_
by the permit is for one hundred dollars ($100) or less.)
SINK CITY C TEL. NO. 0
I certify that in the performance of the work for which this DISHWASHER U
permit is issued, I shall not employ any person in any manner CONTRALTO J
so as to become subject to the Workers' Compensation Laws. CLOTHES WASHER ADDRESS d 0
Date Applicant SWIMMING POOL RECEPTOR U
NOTICE TO APPLICANT: If, after making this Certificate of CITY EL. N 1_7sv� W
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE LIC. to
Compensation provisions of the Labor Code, you must forth- s LICENSE NO. 997 CLASS a5 Z
with comply with such provisions or this permit shall be WATER HEATER
deemed revoked. GAS SYSTEM OUTLETS DISTRICT�FO. PR CESSED BY 1
LICENSED CONTRACTORS DECLARATION OUTLETS OVER ® � �y.J
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000)of Division 3 of the Busi- FINAL ��
ness and Professions Code, and my license is in full force and DATE VALIDATION l�— �Z
effect.
FINAL
License Number____G�1Lic.Class
c� BY
Contractor ate
ElI am exempt from the licensing requirements as I am a Plan check fee
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). TOTAL FEE
Lic.or Reg.No. Date Plan check applicant
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's Address
License Law for the following reason (Section.7031.5, Busi- City Tel.No. _25 6 6 8 A
ness and Professions Code):
DI, as owner of the property, am exclusively contracting i? 0 0 0 0 0 5
with licensed contractors to construct the project
(Section 7044, Business and Professions Code). N° ° 2 0.5 0
CONSTRUCTION LENDING AGENCY .000205030
I hereby affirm that there is a construction lending agency o
for the performance of the work for which this permit is o 1 7 e$2
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
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above-mentiorWd py6perty for inspection purposes.
Zi
Sign ture of ermittee Date