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APPLICATION FOR PLUMB G PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER ;NEAREST
ILDING
BUILDING AN� SAFETY DIVLSION DRESS Jr33'
JOHN A.LAM IE. COUNTY ENGINEER ���' s�
WILLIAM A.JENSEN,SUPT OF BUILDING CALITY
FOR APPLICANT TO FILL IN ST
G
NUMBER FIXTURE OR ITEM EACH FEE GWNE$ / h
la
WATER CLOSET $1.25 MAIL
BATH TUR 1.25 DESS ..�
SHOWER 1.25 CITY �o , ' TEL. NO.
LAVATORY 1.25 CONTRACTOR P#C- /e/I✓.l
SINS 1.25 ADDRESS
DISHWASHER 1.25 CITY Glen&M TEL. NO. .3 / �®
1
CTOR'S STATE
LAUNDRY TUB 1.25 RECON
STRA ION NO. 0. COUNTY ❑
CLOTHES WASHER 1.25 DISTRLCT NO. GROUP Z NE PMCEDWATER HEATER 1.50 D }
GAS SYSTEM OUTLETS 1.50INDUSTRIAL d
WASTE APPROVAL 0
OUTLETS OVER 5 PER SYSTEM .30 INSPECTION RECORD
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O
1 W
a
Z
I
APPROVALS DATE INSPECTOR'S SIGNATURE
PERMIT $ 2 00 UNDER SLAB WORK
ROUGH PLUMBING A
TOTAL FEE GAS PIPING
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION GAS VENT
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL 'COUNTY ORDINANCES AND STATE LAWS 11EGULATING HOT WATER HEATER
PLUMBING. x_.
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR PLUMBING FIXTURES 1
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF GAS TEST _!
CALIFORNIA OR THAT M THE LEGA NER OF,AND INTEND TO
RESIDE IN,THE ABOV SCRIBED RE EN IAL PR ERTY. UTILITY CO.NOTIFIED
Vf 0
SIGNATURE
OF PERMITT FINAL
VALIDATION---')ROBERT A.WOOD
CK. M.0. cnsH SUPERVISING MECHANICAL ENG'R
a02 0 3 SQ OCT 3 0 5 D 3.50-
r
WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
;he„deby,affirm that I have a certificate of consent to self 76AS67A
t, -insure, or a certificate of Workers'Compensation Insurance, CE 817(REV.8/86)
or aacertified copy thereof (Sec. 3800, Lab. C.)
• COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No. Company
Certified copy is hereby furnished.
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING r+2Z
Certified copy is filed with the county building Inspec- ADDRESS V 33�
tion department. NUMBER FIXTURE OR ITEM ® FEE LOCALITY l ~
p�jr�r� P
Date -AppliSant r WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' f BATH TUB �' CROSS 5T.
COMPENSATION INSURANCE OWNER/,
SHOWER
(This section need not be completed if the work Involved by / 6
the permit is for one hundred dollars($900)or less.) ! LAVATORY ADDRESS
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY' ���?�` r TEL.NO. � ]�—�b�
so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers' CITY �/) TEL.NO.7r
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE j LIC.
deemed revoked. WATER HEATER LICENSE NO. j 4,0 CLASS .7
LICENSED CONTRACTORS DECLARATION DISTRICLN0. ROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS i O
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALI TION
DATE
License Number
7360
� Lic. ClassFIN
�/L�,(xtgJy�!/tr�L BY AL C
Contractor y Date i
L
❑ I am exempt under Sec.
B.BP.C. for this reason ® -_9702A
Plan check fee
09 Date:
PLUMBING PERMIT ISSUING FEE$ # 0 0 0 0 0 5
Signature Zef — TOTAL FEE 0 0 2 5 0
SINGLE FAMILY
Plan check applicant o oo 2 8 5 p y0
M "
HOME OWNER-BUILDER DECLARATION Name A4r.,,
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and Address o51 9"87
Professions Code): City t�n� �. Tel. No. 71 6-W V-91
❑ 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
abov a ro ed property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signa re of Permittee Date