HomeMy Public PortalAbout9667 LAS TUNAS DR_Plumbing__ 76A667-CES17 6-60 C—)
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APPLICATIO FOR PLUMBING PERMIT
RETOFCYGEIDEPATTMNCOUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE. COUNTY ENGINEER ADDRESS Li -
WILLIAM A. JENSEN, SUPT OF BUILDING
LOCALITY
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FOR APPLICANT TO FILL IN NEAREST 9
CROSS ST.
NUMBER FIXTURE OR ITEM
OWNER
WATER CLOSET MAIL
ADDRESS
BATH TUB
CITY TEL NO.
SHOWER
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LAVATORY CONTRACTOR •{,;.t,.y .�
ADDRESS
SINK Y
DISHWASHER CITY ' • , TEL. NO. ~'' , J
CONTRACTOR'S STATE
LAUNDRY TUB REGISTRATION NO. / COUNTY El
CLOTHES WASHER DISTRICT O. GROUP ZONE PR ESSED BY
` WATER HEATER 1 1, `-)
/ GAS SYSTEM INDUSTRIAL
WASTE APPROVAL
` 1 i INSPECTION RECORD
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(� $1.00 PER ITEM /
OR FIXTURE S I`� APPROVALS DATE INSPECTOR'S SIGNATURE
PERMIT $ 2 100 UNDER SLAB WORK
TOTAL FEE ROUGH PLUMBING
L GAS PIPING
LDESCRIBED
BY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
TE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY GAS VENT
L COUNTY ORDINANCES AND STATE LAWS REGULATING HOT WATER HEATER
G.
EBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR PLUMBING FIXTURES
D AS REQUIRED BY LOS ANGELES COUNTY AND STATE OFj
NIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE GAS TEST tz
!7 G/ £' r-�..-
ED RESIDENTIAL PROEERTY• UTILITY CO. NOTIFIEDb URE L'ZRMITTE
FINAL
ALIDATION ROBERT A. WOOD,
C[. U.0. CASH SUPERVISING MECHANICAL ENG'R
WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby, affirm that I have a certificate of consent to self in- 20-0026 DPW 4/87 2
sure,or a certificate of Workers'Compensation CE 817 ensation Insurance,or a CE 817 A Llr��1�
(REV. 8/86)
certified copy thereof (Sec. 3800, Lab. C.)
Policy No. l Company COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
El Certified copy is hereby furnished. BUILDING
FOR APPLICANT TO FILL IN (PRINT OR TYPE) ,
Certified copy is filed with the county building inspection ADDRESS
department. NUMBER FIXTURE OR ITEM Oa FEE LOCALITY
Date Applicant WATER CLOSET(TOILET) NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS'
BATH TUB CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS
I certify that in the performance of the work for which this per- SINK
mit is issued, I shall not employ any person in any manner so CITY TEL. NO
as to become subject to the Workers' Compensation Laws. DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
emption, you should become subject to the Workers'Compen- CITY TEL. NO.
sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok- STATE LIC.
ed. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER fs
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDATION
fect. DATE
License Number Lic. Class
FINAL LL
Contractor Date BY y
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I am exempt under Sec.
Q
B.BP.C. for this reason OPlan check feePoo. 4.
Date: PLUMBING PERMIT ISSUING FEE$ W
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Signature TOTAL FEE
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Plan check applicant
hereby affirm that I am exempt from the Contractor's License Name
Law for the following reason (Section 7031.5, Business and w e r r.
Professions Code): Address
4. y
I, as owner of the property, will do the work and the City Tel. No.
structure is not intended or offered for sale(Section 7044, c
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-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date