HomeMy Public PortalAbout10237 OLIVE ST_Plumbing__ CE 817 IRE 781
APPLICATION FOR PLUMBING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN(PRINT OR TYPE( BUILDING
ADDRESS ! v`e i e f A-
NUMBER FIXTURE OR ITEM ® FEE LOCALITY �����
WATER CLOSET
NEAREST _ //--c1
. BATH TUB CROSS ST. z(,e
SHOWER OWNER
LAVATORY MAIL
ADDRESS
SINKCITY 7 TEL.NO'.
DISHWASHER CONTRACTOR
CLOTHES WASHER ADDRESS
SWIMMING POOL RECEPTOR
CITY TEL.NO.
LAWN SPRINKLER SYSTEM STATE LIC..
WATER HEATER rROUGH
O. CLASS
GAS SYSTEM OUTLETS PR VALS DATE INSIE 'S SIGNATURE
OUTLETS OVER ORK
5 PER SYSTEM LUMBINGNG
GAS VENT
HOT WATER.HEATER 99
PLUMBING FIXTURES
GAS TEST
Plan check fee UTILITY'CO.NOTIFIED
PLUMBING PERMIT ISSUING FEE$
TOTAL FEE FINAL
Plan check applicant
PLAN CHECK VAL_IDA`IION v ��� ` `! ,`:�!"•'
Name ! f'!"►i
Address
City Tel.No.
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE 6 51.[I. A
THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES
AND STATE LAWS REGULATING PLUMBING. PERMIT VALIDATION O o o C O 5
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR LICENSED AS o fr�'
REQUIRED BY LOS
LES COUNTY AND
TE OF CALIFORNIA OR T14AT I AM THE
LEGAL OWNER OF.ANDS INTEND TO RESIDES INTHEABOVE DESCRIBED RESIDENTIAL L O o 1 T1O r
PROPERTY.
SIOF PERM ITTEE r� J n GNATURE
0 L �'7 f.
DISTRICT NO. , PRO SSED BY U V / 7
INDUSTRIAL
WASTE APPROVAL
WORKERS'COMPENSATION DECLARATION %f L1CATIdN FOR PLUMBING PERMIT
-`I hereby affirm that I have a certificate of consent to self l76A667A '
insure, or a certificate'of�Workers'Compensation Insurance, !CE 817(REV. 10/81)
or a certified.copy thereof (Sec. 3800, Lab. C.) �' COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No.613363 Company2%;� • ,E �a!a
❑ Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspec- ADDRESS �. Q
tion department. NUMBER FIXTURE OR ITEM @ FEE LOCAUTY`—
WATER.CLOSET tMj LEDate Appli4ant NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER L
Q 0-
(This section need not be completed if the work involved by AN1IL
the permit Is for one hundred dollars($100)or less.) LAVATORY ADDRESS �� V
I certify that in the performance of the work for which this
permit is issued,.I shall not employ any person in any manner SINK CITY t / ■ TEL. NO.
so as to become subject to the Workers'Compensation Laws. I f �►�i
DISHWASHER OO Oo
CONTRACTOR U
Date Applicant CLOTHES WASHER ADDRESS 18 j S
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers' CITY TEL. NO.
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
ft
with comply with such provisions or this permit shall be STATELIC.
'deemed revoked: WATER HEATER LICENSE NO. %277314!7t� CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL. 0
DAT -' VALIDATION �
License Number Lic. Class t3C
FIN O
Contractor Date B U
❑ W
I am exempt under Sec. �
B.&P.C. for this reason
Plan check fee
Date:
PLUMBING PERMIT ISSUING FEE$
Signature 004
TOTAL FEE `(+o
SINGLE FAMILY Plan check applicant
HOME OWNER-BUILDER DECLARATION Name
1 hereby affirm that I am exempt from the Contractor's LicenseAddress r i' 1 A
Law for the following reason (Section 7031.5, Business and
Professions Code): City Tel. No. ` ° ° ° ° C
❑ I, as owner of the property, will do the work and the I u o
structure is not intended or offered for sale (Section
7044, Business and Professions Code). ,'
c_
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.). j
I
Lender's Name 1
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 i
above- pnfi d property fo s ction purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
-�o-g
Signature of Permittee V Date