HomeMy Public PortalAbout5324 MCCULLOCH AVE_Plumbing__ 76A607-CE61710-60r :L
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APPLICATION- FOR PLUMBING -PERMI"T �
COUNTY OF LOS-ANGELES a
DEPARTMENT'OF COUNTY'ENGINEER'
•BUILD G AND SAFETY DIVISION . BiTILDING C
JOHN'A.: AMBLE. COUNTY'ENGINEER 'ADDRESS _ C',
WILLIAM A. JENSEN, SUPT.OF BUILDING
LOCALITY
FOR APPLICANT TO.FILL IN 1REAHEST
CROSS ST. `
NUMBER FIXTURE OR ITEM 1
OWNER O > M
,'Z WATER CLOSET xsa `
ADDRESS 5r 3 Z L• k C
BATH.TUB- F yS•_ _
CITY• TEL:NO. ,
SHOWER '
CONTRACTOR.
Z LAVATORY
SING j.Z� ADDRESS j , LB%ret '
DISHWASHER CITY ! / "TEL..NO. Cp !Q V 6
r CONTRACTOR'S ` STATE
LAUNDRY TUB" REGISTRATION NO..•'.�z 7$�G� COUNTY '
CLOTHES WASHER ' :' Z S'' DISTRICT-pNO. GRO�UP ZONE 'PROCESSED BY
WATER HEATER [SO" ? S Q Q `�,• &y-L_dy d
GAS.SYSTEM j s + -MDUSTBML
WASTE APPROVAL' >: ..
Z4 7 f I",.r' �!7 -. 'f. p]INSPECTION RECORD
. ,�.VN23
$1:00 PER TfER.
OR FIXTURE APPROVALS DATE I. INSPECTOR}HSIGN l6Re i
PERMIT "$ 2100. UNDER SLAB WORK
11 ;•
r ROUH GPL.UMHING -�''IZ�(;.Y `=•"`�';.6"'
TOTAL FEE I3 J r ;
'GAS PIPING J71.
IHEREBY ACKNOWLEDGE THAT 1 HAVE 'READ THIS APPLICATION" i I: - •��! }rf �'
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY GAS VENT
WITH ALL COUNTY ORDINANCES,AND 'STATE LAWS"REGULATING
PLUMBING. HOT WATER HEATER'
I HEREHYCERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR, PLIUMBING FIXTURES
LICEN Efl:)j 9 REQUIRED BY LOS ANGELES•COUNTYlANlJ•STATE'OF n
CALIFORNfA'OR THAT I AM THE'LEGAL OWNER OF THE ABOVE GAS TEST '
DESCRIBED RESIDENTIAL PROPERTY. UTILITY CO.NOTIFIED
SIGNATURE
OF PERM -TER
FILIAL ;
VALIDATION. .. ROBERT A. NY,OO.D
cK M.o, 1 C"H SUPERVISING MECHANICAL-ENG:R
WORKERS'COMPENSATION DECLARATION I APPLICATION FOR PLUMBING PERMIT
I hereby dff ArMriat I'hove 9,certificate of consent to self 20-0026 DPW 6/87
4nsliri4, or a certificate of Workers'Compensation Insurance, 7SA667A
or b,certified copy thereof(Sec. 3800, Lob. C.) COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS
Policy No. Company
Certified copy is hereby furnished. BUILDING —
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS.� tit C CU 1 I Q C( f/
• e,
Certified copy is filed with the county building inspec-
tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Date Appligant I WATER CLOSET NEAREST /�
CERTIFICATE OF EXEMPTION FROM WORKERS' � BATH TUB I CROSS ST. Fee P t2 • 1 j
COMPENSATION INSURANCE SHOWER �. OWNER S heti, eA /(414
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS
I certify that in the performance of the work for which this
permit is issued,I shall not employ any person in any manner 3 SINK CITY TEL. NO.
so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers' CITY TEL.NO.
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO.. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO.`. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS , �0/
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM I
DATE J �Z J VALIDATION
License Number Lic. Class �� I C
FINAL
Contractor Date BY 1Z` C
❑ I am exempt under Sec. C t.
B.BP.C. for this reason Plan check fee _
Date: PLUMBING PERMIT ISSUING FEE$ C b0 ® ACCT.es
Signature TOTAL FEE , ,SQ7 88.010.
Plan check applicant i ITEMS
SINGLE FAMILY TOTAL. 88 o 00
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Address CHECK 88.10
Law for the following reason (Section 7031.5, Business and
PPrro(fessions Code): City Tel. No. CHANGE °)j1
IXl I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section QQy�iQQ� � ��l �I
7044, Business and Professions Code). �
CONSTRUCTION LENDING AGENCY 1500 1 Aid 9:12
1 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'o ermittee Date