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APPLICATION FOR .PL UMBIN PERMIT �
COUNTY OF LOS ANGELES
DEPARDMT OF COUNTY MGM=
BUILDING AND SAFETY DMSION B
UILDING e
JOHN A. LAMBIE, COUNTY ENGINEER WILLIAM A. JENSEN, SUPT OF BUILDING LITYFOR APPLICANT TO FILL IN S.
r
NUMBER FIXTURE OR ITEM OWNER
WATER CLOSET MAIL-
HATH TUB ADDRESS
CITY TEL.NO.
SHOWER
LAVATORY CONTRACTOR
SINS ADDRESS gl/ '7 tA-v�
DISHWASHER CITY7-
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CONTRACTOR'SSTATE
LAUNDRY,TOB REGISTRATION NO. COUNTY C�!!t! e': COUNTY
CLOTHES WASHER �DISTRI NO. GR�p ZONE P CES rBY
WATER HEA ir% ,L�. 1
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GAS SYSTEM � � !VSTR
WASTE APPROVAL }
iINSPECTION RECORD O
V
09
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a
PER ITEM
S 1
(L APPROVALS DATE INSPECTOR'S SIGNATURE
PERMIT $ 2 00 UNDER SLAB WORK
TOTAL FEE ROUGH PLUMBING
GAS PIPING
I HEREBY ACKNOWLEDGE THAT I HAVE READ,THIS APPLICATION t
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY GAS VENTWITH ALL
PLUMBING.
COUNTY ORDINANCES AND STATE LAWS REGULATING HQT WATER HEATER
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR PLUMBING FIXTURES
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF GAS TEST y
CALIFORNIA OR THAT I AM.THE LEGAL OWNER OF THE ABOVE �r / •�
DESCRIBED RESIDENTIAL PROPERTY. UTILITY CO.NOTIFIED
SIGNATURE
OF PERMITTE FINAL
VALIDATION ROBERT A. WOOD
cK. M.o. i CASH SUPERVISING MECHANICAL ENG'R
1
LAC0 3 8 9 OQ� -SEP 4 5 D 3.5 0- 9 .
WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I herel?,y,agirm that I have a certificate of consent to selfah-' " 20-0026 DPW 4/90
sure,-ar a certificate of Workers'Compensation Insurance,ora 76"667A f1
♦sert'ified copy thereof(Sec. 3800, Lab. C.)
COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No. Company
I
Fj Certified copy is hereby furnished. BUILDING
FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS
Certified copy is filed with the county building inspection
department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Ddte Applicant WATER CLOSET(TOILET) NEAREST
CERTIFICATE OF EXEMPTION'FROM WORKERS' �/
BATH TUB CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER /l
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS
I certify that in the performance of the work for which this per- SINK CIN TEL. NO. /
mit is issued, I shall not employ any person in any manner so �'M CJ}' AGO% 6�
as to become subject to the Workers'Compensation Laws. DISHWASHER
1 CONTRACTOR 5 ,5.v47 , CIS!/ii
Date r0 Q r Applicant J CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making j s Certificate of Ex- SWIMMING POOL RECEPTOR /V M o
emption,you should become subject to t e Workers'Compen- CITY _ TEL. NO ��Z ��
sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEMS
ly with such provisions or this permit shall be deemed revok- STATE LIC. r L 4
ed. WATER HEATER LICENSE NO. ?/ Z CLASS �•
LICENSED CONTRACTORS DECLARATION 1 1 DISTRICT NO. CES D BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS ` O
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VA D ION
fect. HOSE BIB DATE l
License Number Lic. Class a
FINAL O
Contractor Date BY
t U
O
I am exempt under Sec.
V
B.&P.C. for this reason ' Plan check feepop. CL
Date: PLUMBING PERMIT ISSUING FEE$ /�, 3p
Signature
TOTAL FEE '3
SINGLE FAMILY Plan check applicant
HOME OWNER-BUILDER DECLARATION PP•cant
I hereby affirm that I am exempt from the Contractor's License Name
Law for the following reason (Section 7031.5, Business and
Professions Code): Address
❑ 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,
Business and Professions Code). Poo.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 i
authorize representatives of this County to enter upon the
above- entioned property for inspection purposes.
��-- SEE REVERSE FOR EXPLANATORY LANGUAGE
Signat of Permitlee ate