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APPLICATION FOR PLUMBING -PERMIT 1
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING 6162 N. Loma
JOHN A. LAMBIE, County Engineer ADDBESS
CASSATT D. GRIFFIN,Sup t of Building. LOCALITY T e e City
FOR APPLICANT TO FILL IN NEAREST
CROSS ST.
NUMBER FIXTURE OR ITEM
OWNER v. e ROSS
1 WATER CLOSET MAIL
BATH TUB ADDRESS
1 SHOWER CITY TEL. NO.
] LAVATORY CONTRACTOR Belvedere Plumbing 'Co
SINK ADDRESS 11900 E. Garvey Ave.
DISHWASHER CITY El Monte TEL. NO. GI 89836
LAUNDRY TUB
REGISTRATION NO. 179568 COUNTY .❑
CLOTHES WASHER !DISTRICT NO. GROUP ZONE P ESS D
1 WATER HEATER � ' I r
GAS SYSTEM INDUSTRIAL
WASTE APPROVAL'
INSPECTION RECORD
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ftp h/y;rggAPPROVALS�0NOc?rve-p
r @ OR FIXTURE 5 I 5�oC DATE INSPECTOR'S SIGNATURE
7 7 UNDER SLAB WORK
PERMIT $ 2100 ROUGH PLUMBING J�j, /�B-rd%i1 /'1-? �A.'UAYl,�O
TOTAL FEE I-��OO GAS PIPING y
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION GAS VENT'
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY HOT WATER HEATER
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING. PLUMBING'FIXTURES '7 /.� Ttti I" i1Jd.C1(Jl /
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR. V _
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF GAS TEST d.
CALIFORNIA OR THAT I AM THE LEGA, OWNER OFLE ABOVE UTI LITY CO.NOTI FI ED
DESCRIBED RESIDENJ PROPERTY. r
SIGNATURE Ile FINAL GORRMAPF_ �� `) /�ye
OF PERM ITTEE �
ROBERT A.WOOD. '
®F VALIDATION SUPERVISING MECHANICAL ENG'R
CK. M.0. CASH v,
ON
M ?.0 1, :.
WORKERS'COMPENSATION DECLARATION CE 81 A APPLICATION FOR PLUMBING . P E R M I T
I hereby affirm that I- have a' certificate of consent to self an (z-eo)
insure, or a certificate of Workers'Compensation Ins ranee,or
a certified co thereof Sec.3800, C.)
�! COUNTY OF LOS.ANGELES BUILDING AND SAFETY
Policy No. -'O Company
Certified copy-is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
ADDRESS 2,
Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM a FEE
�departme t,� WATER CLOSET LOCALITY 7
/�W/Z /�� '
. DateApplicant NEAREST yr
BATH TUB CROSS S �19�
CERTIFICATE OF EXEM ON FROM WORKERS'
COMPEN_ SATION INSURANCE SHOWER OWNE-
,1!�-'
LAVATORY MAIL ] }
(This section need not be completed,if the work involved ADDRESS'.' 0-
byby
the permit'is for one hundred dollars ($100) or less.) SINK
CITY r , Cy. TEL. NO11
'
I certify that in the performance of the work for which this DISHWASHER
permit is issued, I shall not employ any person in any manner CONTRACTOR G / 0
so as to become subject to the.Workers' Compensation Laws.. CLOTHES WASHER
Date Applicant ADDRESS , W
SWIMMING POOL RECEPTOR `ry d
V
NOTICE TO APPLICANT: If, after making this Certificate of CITY i/� TEL. NO.
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM v
STATE 7 / LIC.
Com ensation rovisions of th'e Labor Code, ou must forth- v
withcomplywith such provisions or this permit shall be WATER HEATER LICENSE NO. CLASS
deemed revoked. GAS SYSTEM OUTLETS DISTRICT NO. R CESSED BY
LICENSED CONTRACTORS DECLARATION OUTLETS'OVER r''G e I
I hereby affirm that I am licensed under provisions of Chapter 15 PER SYSTEM
9 (commencing with Section 7000)of Division 3 of the Busi- FINAL / ® ' VALIDATION
-ness and Professions Code, and my license is in full force and DATE
effect.
FINAL
License Number Lic lass BY
Contracto7searchitect
, ate +mpt from the lic nsing requirements as I am a Plan check fee `licenor a registered professional engineer
PLUMBING PERMIT ISSUING FEE$
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.
ness and Professions Code):
❑ I, as owner of the property, am exclusively contracting
with-licensed contractors to construct the project
(Section 7044, Business and Professions Code).
xY55, 1 A
CONSTRUCTION LENDING AGENCY - # 0.010 0 0 5'
I hereby affirm that there is a construction lending.agency
for the performance of the work for which this permit is, 210 0 1'Q,
issued'(Sec. 3097,Civ.C.). ,�
Lender's Name 0 0,0 1 Q
Lender's Address .� 2 9-8 Q
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 rep r sent ti es of this County to enter upon the
above-mentio d pr pity for inspection purposes.
at re o Perm t e Date