HomeMy Public PortalAbout5024 PAL MAL AVE_Plumbing__ 76 A 667 - CE 817 7-69 C.l.rL' 0 T=i�rj?T•,, C%i`�T
APPLICA 909 FOR PLUMBING PERMIT
COUNTY OF LOS ANGELES 13222.
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION U ` ^
'' BUILDING ,
JOHN A. LAMBIE. COUNTY ENGINEER ADDRESS 5C2 No.e r21 tc 1
COLEMAN W. JENKINS. SUPT. OF BUILDING
LOCALTfY 7�en1'le City
FOR APPLICANT TO FILL IN PR NT OR TYPE) NEAREST Lower r-
CROSS ST. Azusc
NUMBER FIXTURE OR ITEM EACH FEE
OWNER '.9 Y' , SI.iiLII
WATER CLOSET 1.50
IL
BATH TUB 1.50 ADDRESS .Sccnme.
SHOWER 1.50 CITY TEL.NO.
LAVATORY 1.50 CONTRACTOR GMMMI
Cp
SINK 1.50 ADDRESS 6558 west 131V&
DISHWASHER 1.50 CITY Lei; Angd s pe TEL.NO. pj $mi
CLOTHES WASHER 1.50 STATE LIC
LICENSE NO. C-S6 151889 CLASS
SWIMMING POOL RECEPTOR 1.50 DISTRICT NO. GROUP ZCAE P O EGSW B
LAWN SPRINKLER SYSTEM 2.00 J * -
r l WATER HEATER 1.50 1 50 INDUSTRIAL
WASTE APPROVAL
GAS SYSTEM OUTLETS 1.50 INSPECTION RECORDOUTL6n
5 PERE SYSTETS M .30 —Readyfor InamuOII N y0
WATER 8OF17X= 3 �..1� Q)
Il<I
H
Plan check fee 25% of above. See reverse.
PLUMBING PERMIT ISSUING FEE S 2 00
TOTAL FEE ZI 50
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
1 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 AND/OR UTILITY CO.NOTIFIED
LICENSED A9 REQUIRED BY LOS ANGELES COUNTY ANO STATE OF
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF,AND INTEND TO
RESIDE IN,THE ADOVE DE®CRIBEDRES TI PRO RTY. FINAL
SIGNATURE • JACK R. ALLEN, SUPERVISI G CHANICAL ENG'R.
OF PERMITTEE /
==J— PERMIT VALIDATIO ' CK M.O. CASH
PLAN CHECK VALIDATION CK. M.O. CASH
3.5
WORKERS'COMPENSATION DECLARATION zease�
I hereby affirm that I have acertificate of consnt to self c E 617 (2-601 'APPLICATION FO® PLUMBING PERMIT
insure,or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.C.) I
n�����n y. 7. i COUNTY OF LOS ANGELES � � BUILDING AND SAFETY
Policy No. Company. 712111th
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
ADDRESS 5024 N. Pal Mal
® Certified co y is filed th t e n ilding inspectio NUMBER FIXTURE OR ITEM ® FEE LOCALITY Temple City
d ar en WATER CLOSET P
Date pelican NEAREST
I BATH TUB CROSS ST.
CERTIFICATE OF TION FRO ORKERS'
COMPE TI INSURA E SHOWER OWNER MAI Lr,
(This section need not be completed if the work involved I LAVATORY AD D R ESS5 0 2 4 N. P a 1 MalJ444—O9
by the permit is for one hundred dollars ($100) or less.) SINK
CITY Temple Cit TEL.NO
I. certify that in the performance of the work for which this DISHWASHER
permit is issued, I shall not employ any person in any manner CONTRACT so as to become subject to the Workers'Compensation Laws. CLOTHES WASHER ADDRESS 1350 E. Las TunaDate Applicant SWIMMING POOL RECEPTOR NOTICE TO APPLICANT: If, after making this Certificate of CITY San GabrielTEL.NO
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE LIC.
Compensation provisions of the Labor Code., you must forth- WATER HEATER LICENSE NO CLASS
with comply with such provisions or this permit shall be
deemed revoked. i 1 GAS SYSTEM OUTLETS 6 00 DISTRICT NO. PR CESSED19Y
LICENSED CONTRACTORS DECLARATION OUTLETS OVER 6
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM ,
9 (commencing with Section 7000)of Division 3 of the Busi- FINAL 6 �� VALIDATION
ness and Professions Code, and my.license is in full force and i DATE
effect. `�
21751 C20 FINAL � ��
License u r Lic.Class BY
Contra c Date
❑ i �'�
am exemp om the licensing requirements as I am a '!Plan Check fee
licensed ar ect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$
acting in my professional capacity (Section 7051, Bus
iness and Professions Code).
TOTAL FEE 16150
Lic,or Reg.No. Date Plan check applicant
HOME OWNER-BUILDER DECLARATION Name Q
I hereby affirm that I am exempt from the Contractor's
Address Q 0 0 0
License Law for the following reason (Section 7031.5, Busi- City Tel.No. ; o (� r C
ness and Professions Code):
❑ I, as owner of the property, am exclusively contracting r t:T
with licensed contractors to construct the project
(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
I
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
su ze representatives. of this County ito/et r upon the
aection p
�Atfire of Per i ee Date