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APPLICATION FOR PLUMBING PERMIT
COUNTY OF LOS ANGELES 1
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE.. COUNTY ENGINEER ADDRESS
COLEMAN W. JENKINS. SUI-T. OF BUILDING LOCALITY p
FOR APPLICANT TO FILL IN NEARCROSS ST. or
NUMBER FUTURE OR ITEM EACH FEE OWNER +•
WATER CLOSET $1.25. MAIL
zAe
BATH TUB 1.25 ADDRESS
CITY TEL. NO.
SHOWER 1.25
LAVATORY 1.25 CONTRALTO '
01
SINK 1.25 ADDRESS
DISHWASHER 1.25 CITY EL. NO�o
LAUNDRY TUB 1.25 STATE LIC
NO. CLASS
CLOTHES WASHER 1.25 STRICT NO. U ZO E I PROCESSED BY
WATER HEATER 1.50 ���i/TOol
�i
GAS SYSTEM OUTLETS -
1.50 WWAASTE APPROVAL 0
OUTLETS OVER 5 PER SYSTEM .90 ]INSPECTION RECORD U
od
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APPROVALS DATE INSPECTOR'S SIGNATURE
PERMIT $ 2 00 UNDER SLAB WORK
ROUGH PLUMBING
TOTAL FEE GAS PIPING
D
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION GAS VENT
ANSTATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING HOT WATER HEATER
PLUMBING. -
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR PLUMBING FIXTURES
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF GAS TEST
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF,AND INTEND TO
RESIDE IN,THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. UTILITY CO.NOTIFIED
SIGNATURE
OF PERMITTEE
FINAL jy
_ UDATION
CK.
M.0. , CASH
j
307E JUN 27 5 D 5.00- 1
I
WORKER'S COMPENSATION DECLARATION ' ;W67APw9,a9 APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified
copy thereof(Sec.3800 Lab.C.) I I
WPO 11 (4834o5oS Company A Y� l 1.5b . COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV.
❑ Certified copy is hereby furnished.
, FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building Inspection ADDRESS
department. NUMBER FIXTURE OR ITEM FEE
LOCALITY G
Date 9 3 Applicant k 3!6!2 X&e-m . 5 WATER CLOSET NEAREST
CROSS ST.
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUBASSESSOR
COMPENSATION INSURANCE MAP BOOK PAGE PARCEL
(This section need not be completed if the work Involved by the SHOWER `
permit Is for one hundred dollars($100)or less.) LAVATORY OWNER
I certify that In the performance of the work for which this permit I
MAIL
Is issued, I shall not employ any person in any manner so as to SINK ADDRESS/ J
become subject to the Workers'Compensation Laws.
DISWASHER CITY TEL.NO. l__�3
Date Applicant CLOTHES WASHER CONTRACTOR eJ
NOTICE TO APPLICANT: If, after making this Certificate of C,•
Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR ADDRESS
provisions of the Labor Code,you must forthwith comply with such
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION CITY TEL.NO.
I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER f -� O
(commencing with Section 7000)of Division 3 of the Business and I O ETS ! / TATEI NO. CLASS 0
Professions Code,and my license is in full force and effect. t !d• til
OUTLETS OVER DISTRICT NO. PROCESSED BY
�• 5 PER SYSTEM Q
License Number � Lic.Class "2• �•
FINAL _VDATE 2—/c.- ALIDATION a
93
Contractor 6)1t�2 5y? Date t 2^h-'4 r►��t :o cc
t ' a LJ Z
I am exempt under Sec. BY AL
Elv.sl �
B.&P.C.for this reason 1 t TEi{S
Date: Plan check fee TOTAL; m 1,35
PLUMBING PERMIT ISSUING FEE$ 1p O p,
Signature TOTAL FEE �J'r CHECK
77 t J
❑ CHANGE .00
SINGLE FAMILY Plan check applicant
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Law 0[i00-000111 12/ $l9-
for the following reason(Section 7031.5, Business and Professions. Address
Code): X292 J 1 PM 12�10
❑ City Tel.No.
I,as owner of the property,will do the work and the structure
is not intended or offered for sale(Section 7044, Business
and Professions Code). ,
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.)
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
pro rty for inspecu es. SEE REVERSE FOR EXPLANATORY LANGUAGE
�,�- I,9
Signature of Perm#tee Date