HomeMy Public PortalAbout9111 OLEMA ST_Plumbing__ fY
r WORKER'S COMPENSATION DECLARATION �. z76Atf87A PW 91� APPLICATION FOR PLUMBING PERMIT
1'h'Ajebj afftrin'tliiat I'have a dertificate,of consent to self Insure,
or a ertificate of Worker's Co;pensation Insurance, or a certified
cop7%ereof(Sec.3800 Lab.C.)
COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV.
Policy No. Company
i
❑ Certified.copy 1s hereby furnished. BUILDING
❑ Certified copy is filed with the county building Inspection FOR APPLICANT TO,FILL.IN(PRINT OR TYPE)j ADDRESS 9111 o emC( sI
department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Date Applicant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST.
COMPENSATION INSURANCE BATH TUB ASSESSOR
(This section need not be completed If the work Involved by the SHOWER 3F
0 MAP BOOK SJ 0 2 PAGE 00J PARCEL
permit Is for one hundred dollara,($100)or less.) x OOWNER �r Q� s. 0SA-CLA e6" t
I certify that in the performance of the work for which this permit LAVATORY
is issued,.I shall not employ any person in any manner so as to SINK 1fADDRESS 9 �� OPI��Cc-
become subject to the Workers'Compensation Laws.
DISWASHER CITY TEL.NO.CPO 0JA)
Date Applicant CLOTHES WASHER CONTRACTOR
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR ADDRESS
provisions of the Labor Code,you must forthwith comply with such
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION WATER HEATER CITY TEL.NO.
I hereby affirm that I am licensed under provisions of Chapter 9. STATE' LIC..
(commencing with Section 7000)of Division 8 of the Business and GAS SYSTEM OUTLETS LICENSE NO. CLASS v
Professions Code,and my license is Infull force and effect. OUTLETS OVER DISTRICT NO. PROC ED BY
5 PER SYSTEM O
License Number Lic.Class
FINAL VALI TION a
Contractor Date / N
❑ I am exempt,under-Sec. BYYL
B.&P.C.for this reason
• Date:
Plan check fee ,
Signature PLUMBING PERMIT ISSUING FEE$
❑ TOTAL.FEEfoo
Plan check applicant 5
SINGLE FAMILYA -�as
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Law
3�17 43.00for the following reason(Section 7081.5, Business and Professions Address
Code): i ITEMS
City Tel.No.
I,as owner of the property,will do the work and the structure TOTAL 43.00
is not intended or offered for sale(Section 7044, Business
and Professions Code). pop. CHECK 43.011
CONSTRUCTION LENDING AGENCY CHANGE .00
0
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. 04.
247 . 1 AM 9°o20
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
76 A 667—CE 817468 -
APPLICATION FOR PLUMBING PERMI
COUNTY OF LOS ANGELES u
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DMSION BUILDING
JOHN A. LAMBIE. COUNTY ENGINEER ADDRESS 9111 018ma St
COLEMAN W. JENKINS. SUPT. OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN PR NT OR TYPE) NET
ST. Encinita 8C I,1V18
NUMBER FIXTURE OR ITEM EACH FEE
WATER CLOSET 1.50 OWNER Rockes
IL
BATH TUB 1.50 ADDRESS same
1 SHOWER an 1.50 50
CITY TEL. NO.
LAVATORY 1.50 CONTRACTOR L M THrAMM,, INC
yy.
SINK 1.50 ADDRESS 2 W. Main Sti•
DISHWASHER 1.50 CITYAlhambraTEL,NO. 282-2151
CLOTHES WASHER 1.50 STATE LIC
LICENSE NO. 1 1 $ CLASS C 6
SWIMMING POOL RECEPTOR 1.50 DICT NO. _ ROUP ZONE P O ESSED BY
LAWN SPRINKLER SYSTEM 2.00 O
WATER HEATER 1.50 wpg STRIALAPPROVAL I L)
GAS SYSTEM OUTLETS 1.50 INSPEC ON RECORD O
OUTLETS OVER ol
5 PER SYSTEM
•30
TC r DW.
Plan check fee 25% of above. See reverse.
PLUMBING PERMIT ISSUING FEE 8 2 00
TOTAL FEE 3 O
APPROVALS DATE INSPECTOR'S SIGNATURE
Plan check applicant UNDER SLAB WORK
Name 'ROUGH PLUMBING
Address GAS PIPING
GAS VENT
City Tel. NO. HOT WATER HEATER
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY PLUMBING FIXTURES
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING GAS TEST
PLUMBING.
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANIVOR UTILITY CO.NOTIFIED
LCALIF
ED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
RNIA OR THAT I M TME LEGAL OWNER OF,AND INTEND TO
IN.THE ABOVE D CHIDED RESIDENTIAL PROPERTY. FINAL v
TURE /: JACK R. ALLEN, SUPEll G CHANICAL EN'G'R.
ERM ITT ��'
PERMIT VALIDATIO CK. M.O. CASH
PLAN CHECK VALIDATION CK. M.O. CASH
�!�'- 3 2 7 .6rF2'. JAI 8 5 9 3.50-