HomeMy Public PortalAbout5421 PERSIMMON AVE_Plumbing__ 76ABB /,
CES�'7(REV.6/78)
es
APPLICATION OR PLU ING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
ADDRESS
NUMBER FIXTURE OR ITEM ® FEEMAN A CI
.
WATER CLOSET LOCALITY
NEAREST I
BATH TUB CROSS ST.
SHOWER OWNER dSL)
LAVATORY MAIL
ADDRESS �
SINK CITY'rF TEL.N041118
DISHWASHER CONTRACTOR
CLOTHES WASHER ADDRESS cs- IT
SWIMMING POOL RECEPTOR
' CIN TEL.N
LAWN SPRINKLER SYSTEM ANAr
STATE LIC.
WATER HEATER LICENSE NO. CLASS e,�'
GAS SYSTEM OUTLETS APPROVALS DATE INSPECTOR'S SIGNATURE
OUTLETS OVER UNDER SLAB WORK
5 PER SYSTEM ROUGH PLUMBING
GAS PIPING �r�f"'�
-GAS VENT
HOT'WATER NEATER
PLUMBING FIXTURES
GAS TEST
dUTILITY
Plan check fee CO.NOTIFIED
PLUMBING PERMIT ISSUING FEE$ 4e
TOTAL FEE r FINAL
Plan check applicant PLAN CHECK Vf�L,�_DATI N
Name �
Address U"G D
City Tel.Nb.
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE
THATTHE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES
AND STATE LAWS REGULATING PLUMBING. PERMIT VALIDATION ` Q
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/.OR LICENSED AS `5 6 2 8 A
REQUIRED BY LOS ANGELES COUNTY AND STATE OF CALIFORNIA.OR THAT I AM THE '
LEGAL OWNER OF,AND INTEND TO RESIDE IN THE ABOVE DESCRIBED RESIDENTIAL # 0 O o O o 5
PROPERTY. //�`� '�`/f
SIGNATURE �v ` C O 1 0 0 0
OFPERMITTEE 0 0'0 1 (loom
DISTRICT NO. Q PROCESSED BY 0723-79
INDUSTRIAL
WASTE APPROVAL
+ :MORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
( 76A666 DPW 4/87
I.hereby, affirm that I hove a certificate of consent to self in- 76A667A
sage,or a certificate of Workers'Compensation Insurance,or a CE 817(REV.8/86)
certified copy
}thereof
G(S�ec. 3800, Lab. C.) )-_ r � COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS,
Policy No.292r- 9 • Company 6*QTS ryl;
❑ Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING 5 o f5i
91 Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM ADDRESS U VYJ►�'f L�✓1
department. @ FEE
y WATER CLOSET(TOILET) NEAREST 6 LOCALITY t° 1ate-
Date
l�
5-/7-q/
Date Applicant Gi���^`� �
CERTIFICATE OF EXEMPTION FROM WORKERS'
BATH TUB CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER (J/h
(This section need not be completed if the work involved by MAIL
the permit Is for one hundred dollars ($100)or less.) 7_ LAVATORY ADDRESS � (�•
I certify that in the performance of the work for which this per- SINK /JQ 1
mit is issued, I shall not employ any person in any manner so CITY TEL. NO.
as to become subject to the Workers'Compensation Laws. DISHWASHER L
CONTRACTOR Q5v/' emodep _s
Date Applicant CLOTHES WASHER ADDRESS �/
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
emption,you should become subject to the Workers'Compen- SWIMMING POOL RECEPTOR
sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEM CITY e V)xA_ TEL. . 9&9,z9Sj
ly with such provisions or this permit shall be deemed revok- STATEp 2Q LIC.
ed. WATER HEATER LICENSE NO. 1 F_3 / CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PR CESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS �� (j t
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER T�
fed Professions Code, andmy license is in full force and ef- 5 PER SYSTEM FINAL VALIDATIO a
�fI-S03 / _ b DATE 2 O
License Number Lic. Class V
Contractor� Date 5 FINAL
BY O
a-
1 am exempt under Sec. W
B.&P.C. for this reason ® U)
Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$ Joao
Signature TOTAL FEE
SINGLE FAMILY Plan check applicant J
HOME OWNER-BUILDER DECLARATION PP
I hereby affirm that I am exempt from the Contractor's License Name F�..�` =a Ir a
tt
Law for the following reason (Section 7031.5, Business and
Professions Code): Address 65.-'1=
❑ I, as owner of the property, will do the work and the City Tel. No.
structure is not intended or offered for sale(Section 7044, --jl`�� � m
Business and Professions Code). ®
50
CONSTRUCTION LENDING AGENCY '-HEIEC '
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 0000-11-001 1 O1
.17
tV-4
.f a
i
+I7T i I-i v�_�7
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 roperty for inspection purposes.
-5-17-'91 SEE REVERSE FOR EXPLANATORY LANGUAGE
S' nature of Permittee Date