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APPLICATION FOR , PLUM'BI G 'PERMI
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING ]_50/_ - oak
JOHN A. LAMBIE. COUNTY ENGINEER ADDRESS l9 l4 �t
WILLIAM A.JENSEN, SUP'T.OF BUILDING LOCALITY
FOR APPLICANT TO FML IN NEARESTET.
NUMBER FII�TURE OR ITEM EACH FEE
OWNER IIV1l�1U1t�t.
WATER CLOSET $1.25
BATH TUB 1.25 "ADDRESS 01
CITY CtArq� a TEL.NO. N-L-725 17
SHOWER 1.25
LAVATORY 1,25 CONTRACTOR(( fjdAke P {� "a
SINK 1'.8s Z ADDRESS 1�Y. 17 F. OLww Q. OaI ud.
DISHWASHER 1.25 CITf3�(�& �,• TEL. NO d-8 112 ,..
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LAUNDRY TUB' 1.25 REGISTRATION NO. 1�77 7 - COUNTY
CLOTHES WASHER 1.25 DISTRIC NO. GROUP ZONE P SED BY
WATER HEATER 1.50 C7j�
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GAS.SYSTEM • OUTLETS 1'50 IL
WASTE INDUSTRIAL
PROVAL IL
OUTLETS OVER 3 PER SYSTEM .30 fl INSPECTION RECORD V
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ALA
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APPR.O,/gQ.S DATE INSPECTOR'S SIS.-OURE
UNDER,4ISA7B WORK
PERMIT $ 2 00 ' p�•�l '"•"
OUGH PLUMBING pv E ✓°��'+
TOTAL FEE I g GAS PIPING
1 HEREBY ACKNOWLEDGE THAT I 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
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1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR PLUM BI NG.FIXTU RES /
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT 1 AM E L AL OWNER OF NO INT D TO GAS TEST ✓"�"`^-�
RESIDE IN,THE ABOVE BED SIDENTI RTY. UTILITY CO.NOTIFIED
SIGNATURE
OF PER?
T1011111 FINALWA�, fig
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ALIDATION ROBERT A.WOOD
M.O' CASH SUPERVISING MECHANICAL ENG'R
u 8 9 9.:o'G VIM 1 5 D 8.2 5-. cz
WORKERS'COMPENSATION DECLARATION 176AS67A
I hereby affirm that I have a' certificate of consent to self cE 6+7 (2-80) APPLICATION FOR PLUMBING PERMIT
insure,or a certificate of Workers'Compensation Insurance,or I 7
a certified copy the; o (S7C' Vec. 800,Lab.C.) COUNTY OF LOS ANGELES , ' BUILDING AND SAFETY
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
Certified co NUMBER FIXTURE OR ITEM ® FEE ADDRESS
copy is filed with the my Iding insp
de art Irk WATER CLOSET LOCALITY
ig
Date d Applicant NEAREST
BATH TUB CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE SHOWER OWNER
(This section need not be completed if the work involved LAVATORY MAIL ,/
ADDRESS rp a
by the permit is for one hundred dollars ($100) or less.) F O
SINK CITY' TEL.NO.
I certify that in the performance of the work for which this DISHWASHER
permit is issued,I shall not employ any person in any manner CONTRACTOR O
so as to become subject to the Workers'Compensation Laws. CLOTHES WASHER ADDRESS . a® ® IFU
Date ApplicantW
SWIMMING POOL RECEPTOR
NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL.NO VP
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE /� LIC. -�
Compensation provisions of the Labor Code,you must forth- WATER HEATER LICENSE NO. �V CLASS
with comply with such provisions or this permit shall be
deemed revoked. GAS SYSTEM OUTLETS DISTRICT NO. PR CESSEP BY
LICENSED CONTRACTORS DECLARATION OUTLETS OVER _5 - Q(�
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000)of Division 3 of the Busi- FINAL r VALIDATION
ness and Professions Code, and my license is in full force and DATE
effect.
License Numbe �®Lie.Class FINAL
Contractor Date /
I am exempt ffoom the licensing requirements as I am a Plan check fee
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). TOTAL FEE
Lie.or Reg.No. Date Plan check applicant
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's Address 0 5 1 1.5
A
License Law for the following reason (Section 7031.5, Busi- City Tel.No.
nets and Professions Code): 0 0 0 0. 0 5
1, as owner of the property, am exclusively contracting
with licensed contractors to construct the project 2 0 0 I GO 0
(Section 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency 0 505-8 1
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 SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances and State laws regulating Plumbing, and hereby
authorizer resentatives of thi County to enter upon the
a me n property for'u tion urposes.
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Signature of Permittee Date