HomeMy Public PortalAbout8748 LONGDEN AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION APPUCAIMN FOR PLUMENG NG PERNT
I hereby affirm that I have a certificate of consent to self 76A667A
ir' urs. o; oMertificofe of Workers' Compensation Insurance, CE 817(REV 10/81)
o cef nfltd copy thereof (Sec 3800, Lab C ) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No Company
❑ Certified copy is hereby furnished
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING �
Certified copy is filed with the county building inspec- ADDRESS 1)It J G
tion department NUMBER FIXTURE OR ITEM @ FEE
LOCALITY s� &A 1 G
WATER CLOSET
Date Applicant BATH TUB CROSSSTUSC (—
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE SHOWER OWNER 'PAL Ma 0 S E ZTE TM Cd S
(This section need not be completed if the work involved by MAIL
c. I
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS DRESS o N Co Z)6_
+ I certify that in the performance of the work'for which this
permit is issued, I shall not employ any person in any manner SINK CITY ,�I TEL NO
so as to become subject to the Workers'Compensation Laws /v
4 DISHWASHER CONTRACTOR
Date bra Apphcan CLOTHES WASHER
ADDRESS
NOTICE TO APPLICANT If, after making this Certificflq of
Exemption, you should become subject to the rkers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code,You must forth- CITY TEL NO
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC
deemed revoked. WATER HEATER LICENSE NO
LICENSED CONTRACTORS DECLARATION IDISTRIC� P ESSEMBY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS r Q�
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER / _!�
and Professions Code,and my license is in full force and effect 5 PER SYSTEM, FINAL //¢ //� VALIDATIO ,
License Number Lic Class DATE
v IIIJJJ a
FINA U
Contractor Date BY fY
❑ I am exempt under Sec 0
B&P C for this reason W
Plan check fee CLI
DateDate PLUMBING PERMIT ISSUING FEE$ Z
Signature
TOTAL FEE
SINGLE FAMILY
Plan check applicant-
- ''�• •
HOME OWNER-BUILDER DECLARATION Name L V .S I 7GTRA�(3S
I hereby affirm that I am exempt from the Contractor's License ;25 2.8 4 A
Low,for the following reason (Section 7031 5, Business and Address g 14 g C
Professions Code) City S <__ # 0'0 0 0,a 5
. Tel No �o
I, as owner of the property, will do the work and the 0,0 2 0 5 0
structure is not intended or offered for sale (Section .0 0)0 2 5 0 57044, Business and Professions Code) '
CONSTRUCTION LENDING AGENCY 0 a 2 0+8 b
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-mentioned property for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE •
Signature of Permittee Date
76AO67-CE#817 9/63 ® '
APPLICATION FOR PLUMBING PERMIT u
COUNTY OF LOS ANGELES u
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE. COUNTY ENGINEER ADDRESS
WILLIAM A JENSEN, SUPT OF BUILDING LOCALITY
FOR APPLICANT TO FILL"IN NEAREST
CROSS ST.
NUMBER FIXTURE OR ITEM EACH FEE Ic It
OWNER
WATER CLOSET $1.25 MAIL ry '
BATH TUB 1.25 ADDRESS �< `''I
SHOWER 1.25 CITYs� / L. NO.
LAVATORY 1.25 CONTRACTOR
SINK 1.25 ADDRESS
DISHWASHER 1.25 CITY �, TEL. NO. -Cj-/
LAUNDRY TUB 1.25 CONTRACTOR'S STATE
REGISTRATION NO. COUNTY ❑
CLOTHES WASHER 1.25 DISTRICT NO. GROUP ZONE PR ES D BY
WATER HEATER 1.50 /
GAS SYSTEM OUTLETS 1'50 INDUSTRIAL D_
WASTE APPROVAL O
OUTLETS OVER 5 PER SYSTEM .30 INSPECTION RECORD U
DC
O
F-
U
W
O.
N
Z
APPROVALS DATE INSPECTORS SIGNATURE
PERMIT $ 2 00 UNDER SLAB WORK
4 ROUGH PLUMBING �y
TOTAL FEE e�✓( GAS PIPING
I HEREBY ACKNOWLEDGE THAT 1 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 AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF GAS TEST
CALIFORNIA OR THAT I AM THE LEGAL OWNER ,�F,AND INTEND TO
RESIDE IN,THE ABOVE DESCRIBE SI NTIA OPERTY UTILITY CO NOTIFIED
SIGNATURE �,/i
OF PERMITTEE vvVV /y B!/
FINAL G
T VALIDATIO ROBERT A WOOD !-
CK M o CASH SUPERVISING MECHANICAL ENG'R
Y ,9 9 93 1 JUN 11� 5 R
NINE=
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DEPARTMENT OF BUILDING AND SAFETY' APPLICATION FOR P�'�
`�OIIPt'T'Y OF LOS ANGELES PLUMBING
Mew.J.FOX.CHIEF ixa1NEER
A RE OF 0..T.0 LATIO DiSTR C Jo Arr NO. r
ROUGH PIXTURE9 I COMPLETQ
• R / T�
HQATHR CCl4POOL s[PTIC TANK --_ RaCQIYI,p DY 6ADY FOD�t�'S 1DIIU[D '�+a
FiR QT IN6P[CTION
A8 M QC LANEOt:V
APPLICANT FILL IN NEAVI".Y OUTLI ED ?ORTION ONLY :
¢ NAS
Lyman F. Harry JOIS61 Das .Ong en _ +
m Acmowe" AT 1-03$5 LO VALr7Y
a z
D 3 San rjabriel
c,ry San Gabriel 4.yll;-Y�x �RCIZA_TT.
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a
Ci ['ZPIRE! b 30/50 C NAME iy�.n r. 1�;$rry �•
LOCATION OF SEPTIC TAINK. OR CESSPOOL z MAIL 931 E. Longden
ADDR[S8 ,
NORTH G 2
C" c..R r (:a O1 r 1 e 1 y EL..�1 w .,-2',.40
I AM THE LtQAL PO"TSSOR OF THZ Pl9Yi LOS -
I ANGELES COUNTY CXATItICATE OF CUAL�IFt��/l
. .
y
I AM THE LEGAL CWN[R OF THE PROPERTY=Q=CRfIlcZ,D �
> '7
OWN,=CORRECTIONS
DESCRIPTION FORK = ,
lI3F,WA9HC3
0 i
VATORY Ar"IOERATOR
!m OINK WATER SOFTENER
rW7ALT=
SINK QANnTRAPBINK nOOR DRAIN
SH TRAY URINlL :iPPROVALS CLOUT ZRINKINO FOUNTAIN UnTEn+saac�rynwrYTUZZ Ho'..iirn "ENI AL LAVATORY ROVON PLUMBING I
T� n �^A FOUNTAIN CAD PIPING I jt
OUTL
OAII VEKT
CE9HPOOL n.
TOTAL k"8101 aP '�!. ,'A•�' g[PT1G TANK
nIIPTIC TANK 4rWER
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UTILITY CO.NOTIP ZD 1
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