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APPLICATION FOR PLUMBING PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County. Engineer ADDRESS t/
CASSATT D. GRIFFIN, Sup t of Building LOCALITY
IL
FOR APPLICANT TO FELL IN NEAREST
CROSS ST.
NUMBER FIXTURE OR ITEM
OWNER '
WATER CLOSET MAIL a�
BATH TUB ADD M1
CITY TEL NO
SHOWER _ /' s /
LAVATORY CONTRACTOR Owl'✓ '1r-
SIN>; ADDRESS
DISHWASHER CITY TEL. NO. '
CONTRAC S STATE
LAUNDRY TUB REGIS N NO COUNTY ❑
CLOTHES WASHER DISTRICT NO. g$>JUP ZONE P CESSED BY
WATER HEATER C4
GAS SYSTEM INDUSTRIAL
WASTE APPROVAL
INSPECTION RECORD
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PER
OR DCTTUR $ I ! B �O FYI GOMPL� �D-dZC O7i,�
APPROVALS DATE INSPECTOR'S SIGNATURE
PERMIT $ 2100 UNDER SLAB WORK
TOTAL FEE Q ROUGH PLUMBING
GAS PIPING
1 HEREBY ACKNOWLEDGE THAT 1 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
PLUMBING. HOT WATER HEATER
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR PLUMBING FIXTURES
LICENSED AS REQUIRED BY LOS A ELES COUNTY AND STATE OF GAS TEST
CALIFORNIA OR THAT I TH LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL OPY. le
UTILITY CO NOTIFIED
SIGNATURE
OF PERMITTE
lvlx�4
FINAL
OF VALIDATIOJ9--, ROBERT A. WOOD,
CK. ®,o. (CASH SUPERVISING MECHANICAL ENG'R
Co5 7 6'3 JAN 2 8 5 A 3.0 0 M
"xg" 1y APPLICATION FOR PERMIT
DEPARTMENT OF BUILDING AND SAFETY
COUNTY OF LOS ANGELES
WILLIAM J. FOX, CHIEF ENGINEER
FOR APPLICANT TO FILL IN' DISTRICT NO. GROUP ZONE PERMIT NO.
PLUMBER G/-' �/ y�}U /� RECEIVED BY FIRST INSPECTION /DY FOR DSA SU€RD4
ADDRESS CO'� I 8. h Q� "1 �/7 //V"s�5!'6v'�/-7 /tJY 6...
"AFF
—if
]. BUILDING
�I�1 /� INO.,/;7.t/- 3COUN�Y ® V ADDRESS�'��
CITY / 1 //yam/ TEL j, f
LICENSE NO l.9/ �7 / 7 EXPIRES /a LOCALITY�����I� !
NEAREST
PERMIT FEES CROSS ST.
NUMBER I TYPE OF FIXTURE OR ITEM FEE OWNER
MAIL
WATER CLOSET (TOILET) Q O 501S I ADDRESS
BATH TUB Q O 50 I _ CITY TEL. NO
SHOWER Q 0.501 I 1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS
LAVATORY (WASH BASIN) Q O 50 I APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND
_ AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND
KITCHEN SINK Q O 501 STATE LAWS REGULATING PLUMBING
I CERTIFY THAT 1 POSSESS THE ABOVE VALID LOS
LAUNDRY TUB OR TRAY Q O Sol ANGELES COUNTY LICENSE OR I AM THE LEGAL OWNER
OF THE RESIDENTIAL PROPERTY DESCRIBED ABOVE.
GAS SYSTEM OUTLETS Q O SOI SIGNATURE OF (��
WATER HEATER Q O Sol PERMITTEE0�
SLOP SINK Q O 50 SP
FLOOR SINK Q O 50
FLOOR DRAIN Q O Sol
DISHWASHER Q O 501
DRINKING FOUNTAIN Q O Sol
URINAL Q O 501 I „I
HOUSESEWER Q O 50) I Q
Z
MISCELLANEOUS / , I I -0
1 1140
v I i O
I I _
I�
I I
APPROVALS
DATE INSPECTOR'S NAME
ROUGH PLUMBING
GAS PIPING
I- GAS VENT
CESSPOOL Q 1 00 CESSPOOL
SEPTIC TANK I SEPTIC TANK
I DRAIN ( ) PIT ( ) QDRAIN ( ) PIT ( ) 1.001 SEWER
PERMIT . I 1 00 GAS TEST
UTILITY CO NOTIFIED
I TOTAL FEE $ � FINAL C/
1
;WORKERS'COMPENSATION-DECLARATION 20 - APPLICATION _FOR PLUMBING .PERMIT:"
I hereby,;;#firm that I Have a certificate of consent to,self in- 76A667A FW 4/97"
L
sure or a certificate of Workers'Compensation Insurance,ora CE 817(REV 8/86) ,+ t
cerhf+ed copy thereof (Sec 3800, Lab C)
��� // /��9%�piJt✓ 011 r COUNTY OF„LOS ANGELES - DEPT. OF PUBLIC KS
:Poli cj No s, WORKS
_❑"Certified copy,is hereby furnished
FOR APPLICANT°TO FILL IN (PRINT,OR TYPE): BUILDING / Z a;,t Y `•
ertified copy is filed with•t_he county building inspection - ADDRESS ']J (/
department NUMBER ' FIXTURE OR ITEM (al''` FEE
LOCALITY
D
fr
ate G CERTIFIC�TE OF EXEMPT'ION,FROM WORKERS'Applicant,-'L�s✓/f/l , ' f'!� WATER—CLOSET(TOILET), NEAREST
- ' BATH TUB ' O CROSS ST '
COMPENSATIOINSURANCE' OWNER,
a SHOWER" =�
�.. °
(This section need not be completed if-the work'in'voiwed by MAIL 4
the'.permlt is for one hundred dollars ($100)or'le'ss.),. '�rt 'LAVATORYc' .. - ADDRESS •� ,�
1-certify that'in the performance of the work for which this peg`- SINK
mit is'issued,-I,shotI not employ onylperson•in any manner-so ' CITY TEL NO '
as to,become sublect.to the,Workers'Compensation Laws 5 A DISHWASHER y
CONTRACTOR �✓(S,
Date Appheaht ' CLOTHES WASHER q t r e
NOTICE TO APPLICANT If, after making ihis;Certificate•of Ex.
ADDRESS
NOTICE i
a. SWIMMING POOL RECEPTOR '
emphon,'you sho"uld become sub(ect to,the Workers'Compen- CITY /A/ TEL NO
sation'provisioris.of the Labor Code,'you must forthwith comp,-• LAWN SPRINKLER SYSTEM i - ' ��^�
.ly with such-provisions or this permit shall be deemed revok- STATE LIC '
ed , _ WATER HEATER LICENSE NO CLASS
LICENSED CONTRACTORS DECLARATION:- • - - DISTRICT NO- OCESSED BY, ;
r GAS SYSTEM; ,: OUTLETS -
Thereby'affirm that I am licensed under provisions of Chapter• r - � -
9(commencing with Section 7000)of Division 3 of the Business- OUTLETS OVER <
'
and Professions Code, and my 5 PER SYSTEM license is in full force and ef- FINAL VALIDATION,
tett `! � DATE 1 �'� a0
License Number Y��� Lit Class /� „ O
A FINAL Q
Contra �AlG� Date _
BY, O
I am,exempt under Sec W
B 8P C for this reason CL
plan.check fee ►
ate I
PLUMBING,P-ERMIT,ISSUING FEE $
i Signature r
TOTAL FEE
SINGLE FAMILY.
HOMEOWNER-BUILDER DECLARATION r ?Ian.check applicant s
Thereby affirm that I'am exempt from the Contractor's License ' Name C, � "
Law for the following,reason (Section 7031 5, Business and
Professions Code) i1, Ir
I 'a's owner-of the property,:will do the work and the• Gty �, - fel'No' FC-0
structure-is riot intended or offered for sale(Section'/V44-,-
Bus
iness
044•_Bysiness and Professions Code) i 3r_7f•= _
' 65 50
CONSTRTION LENDING AGENCY �. �
UC
a _
I'hereby affirmthat there) ' construction lending agency for j; • q 9 y r.HEtC�
-the performonce,of the work'for which this permit.is issued ' ti E_
(Sec 3097, Civ C ) C•HWE—
Lender's;Name
" _ r • �• _ �;!5i�I!—iii_I_t �!4
Lerider's Address ° :e 5
7• ( '>c
I certify that I have read,this application and state that the i' ,r c _ ` ' 0!4 i _ i(fi I ty`
above information is correct I agree to comply with all County y - '- y -
ordinances and_State,laws regulating,Plumbing, and hereby N111'. - wl
authorize representatives f_ this County to enter upon-the
above-mentioned pro e .for inspection purp es
SEE REVERSE+•`FOR EXPLANATORY LANGUAGE ' ;i•• . ,
Signatufe cf Permitt a Da r `