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HomeMy Public PortalAbout6448 LOMA AVE_Plumbing__ 76A667C (CE78176) -9/75 ' APPLICATION FOR PLUMBING PERMIT BUILDING AND SAFETY DIVISION FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING NUMBER FIXTURE OR ITEM ADDRESS 0Y�'J �j�,. @ FEE WATER CLOSET 3 '� LOCALITY NEAREST ,, y! BATH TUB CROSS ST. {ova 'G .( SHOWER � OWNER LAVATORY MAILADDRESS SINK 3 -�' CITY TEL. NO. DISHWASHER CONTRACTOR CLOTHES WASHER ADDRESS - SWIMMING POOL RECEPTOR LAWN SPRINKLER SYSTEM CITY '. �r - TEL. NO. 3 STATELIC WATER HEATER 3 LICENSE NO. / CLASS a 1 GAS SYSTEM OUTLETS D,IIS'T`RICTQNo. GROUP ZONE P OCESSED BY V OUTLETS OVER C Chi V I O 5 PER SYSTEM INDUSTRIAL U WASTE APPROVAL Ly INSPECTION RECORD fCL. Plan check fee PLUMBING PERMIT ISSUING FEE $ 4 SD OTAL FEE .5-C7 Plan check applicant Name �' APPROVALS DATE INSPECTOR'S SIGNATURE UNDER SLAB WORK -'`�'� 7/ Address o3 eu ROUGH PLUMBING City ! Tel. N �J GAS PIPING I 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. a _ I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR PLUMBING FIXTURES � %gd`+ �,,,, LICENSED AS REOUI RED BY LOS ANGELES COUNTY AND STATE OF GAS TEST CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO RESIDE IN THE ABOVE D RIBED RESIDENTIA P OPE Y. UTILITY CO. NOTIFIED SIGNATURE OF PERMI TT FINA PLAN CHECK VALIDATION CK. M.O. CASH PERMIT VALIDATION CK. M.O. CASH 115, 5 '0 2.911 5 5 �; 2 8.5 ©-ears t WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a certificate of consent to self 76A667A insure, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81) or a certified copy thereof (Sec. 3800, Lab. C. COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company � � Certified copy-is hereby furnished. r FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING // i7 � py Certified copy is filed with the county building inspec- ADDRESS (C? •_ /V a . �C2.k f tion department. NUMBER FIXTURE OR ITEM @ FEE _ LOCALITY Date�f�� Applicant `� WATER CLOSET NEAREST Olt- CERTIFICATE OF EXEMPTION FROM WORKE ' BATH TUB CROSS ST. COMPENSATION INSURANCE SHOWER OWNER (This section need not be completed if the work involved by MAIL ,f the permit is'for one hundred dollars(;100)or less.) LAVATORY ADDRESS 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. NO. so as to become subject to the Workers Compensation Laws. DISHWASHER CONTRACTOR Date Applicant CLOTHES WASHER L/ ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR CITYTEL. NO. f -� Compensation provisions of the Labor Code, you must forth- iia LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE �. .� LIC. y deemed revoked. WATER HEATER LICENSE NO. �a � 7 CLASS LICENSED CONTRACTORSDECLARATION DIST!! T NrX SSED BY I hereby affirm that I am licensed under provisions of Chapter 9 u GAS SYSTEM OUTLETS / (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER ye and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINALVALID TION License Numb4,- L/ Lic. Class_(f S13 DATE 2 -15;_ ' U J ClFINA Contractor -I/y Pr-143 4S Date 7-4'_�5 BY . ❑ I am exempt under Sec. B.&P.C. for this reason Plan check fee Date: PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE X355,4- A Plan check applicant SINGLE FAMILY # 0 0 0 0 6 5 HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Address ( °.° 1 6,50 Law for the following reason (Section 7031.5, Business and Professions Code): City Tel. No. •:•0 o o 1 6.5 0 v ❑ 1, as owner of the property, will do the work and the 1 �,27-6-85 structure is not intended or offered for sale (Section , 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a 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 above m ntioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Er Date