HomeMy Public PortalAbout9539 PENTLAND ST_Plumbing__ 76A667-CE#817 4-67
APPLICATION FOR PLUM�NG PERMIT
COUNTY OF LOS ANGELES •
DEPARTMENT OF COUNTY ENGINEER Q `,
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
JOHN A. LAMBIE. COUNTY ENGINEER
COLEMAN W. JENKINS. SUPT. OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN NEAREST
.CROSS ST.
NUM,SER FIXTURE OR ITEM EACH FEE
OWNED V
WATER CLOSET $l.
All MAIL
r BATH TUB 1 5 ADDRESS
SHOWER 1 5 CITY TEL. NO.
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LAVATORY 1.25 CONTRACTOR
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SINK 1.25 ADDRESS
DISHWASHER 1.25 CITY V�'' — TEL. NO._SATE LIC
LAUNDRY TUB 1.25 LICENSE NO. � CLASS
CLOTHES WASHER 1.25 DISTRICT NO. GROUP ZON P CE .D By,
WATER HEATER 1.50
GAS SYSTEM OUTLETS 1.50 ,INDUSTRIAL
,,WASTE APPROVAL
OUTLETS OVER 5 PER SYSTEM .90
INSPFCTION RECORDCD
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APPROVALS DATE INSPECTOR'S SIGNATURE
PERMIT S 2 00 UNDER SLAB WORK
ROUGH PLUMBING
TOTAL FEE . - GAS PIPING 1
I HEREBY ACKNOWLEDGE' THAT 1 HAVE READ THIS APP ICATIdN ;GAS VENT
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND. STATE LAWS REGULATING HOT WATER HEATER
PLUMBING.
IHEREBY 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 LEGAL OWNER OF,AND INTEND TO
RESIDE IN.THE ABOVE DES 1 O RESIDENT, ROPERTY. i UTILITY CO. NOTIFIED
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SIGNATURE L--
OF PERMITTEE r
FINAL
��AIJDATION '. .TACK R.ALLEN
M.0. CASH SUPERVISING MECHANICAL ENG'R.
j ,;3.4 l 3:12 PEAR 4 5D 9:15:0ce
WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
F. +
tiI y affirm that I have a certificate of consent to self 76A667A
insure; or a certificate of Workers'Compensation Insurance, CE 817(REV. 10/81)
or a certified copy thereof(Sec. 3800, Lail. C.) i COUNTY OF LOS ANGELES ' BUILDING AND SAFETY
ac6g6679 Com aC^A STATE FUND #40722
P Y
Certified copy is hereby furnished. BUILDING
❑X Certified copy is filed with the cou6ty building in.spec- FOR APPLICANT TO FILL.IN(PRINT OR TYPE) ADDRESS 9539 Pentland Street
tion department. NUMBER FIXTURE OR ITEM @ FEE
LOCALITY
Date Appl igant WATER CLOSET NEAREST Tamplp City
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. A l l esand r0
COMPENSATION INSURANCE SHOWER OWNER Mr. ad Mrs. DU er
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars($100)or less.) LAVATORY I ADDRESS 9539 Pentland Street
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner., SINK CITY Tem l e City TEL.NO-286-8494-
so as to become subject to the Workers'Compensation Lows. DISHWASHER CONTRACTOR
E. L. PAYNE CO
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of 14823 ral i fa Street
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY Van Nuys 7EL, N
LAWN SPRINKLER SYSTEM O. 793-1 131
with comply with such provisions or this permit shall be STATE 120228 LIC. C-20
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION6 0057 O. P ESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 1 GAS SYSTEM OUTLETS
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL0
DATE ,� VAL DATION, u
License Number 120228 Lic. Class C-20 09
Contractor E. L. PAYNE Date' 7-22-85 . I F111 00
❑ W
I am exempt under Sec. N
B.&P.C. for this reason �
Plan check fee
2778
Signature
Date:. PLUMBING PERMIT ISSUING FEE$ 10 50 #o 0 o o;o 5
TOTAL FEE 16 50 ,( o 0 1 6,15 0
SINGLE FAMILY Plan check applicant 0 0 01 6506
HOME OWNER-BUILDER DECLARATION Name 2 2
I hereby affirm that I am exempt from the Contractor's License Add5
Law for the following reason (Section 7031.5, Business and Address 8 e
Professions Code): City Tel. No. 0
❑ 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
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
ab e-mentioned property for inspection purposes.
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SEE REVERSE FOR EXPLANATORY LANGUAGE
7-99-85
Signature of Permittee Date
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