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HomeMy Public PortalAbout5639 PERSIMMON AVE_Plumbing__ sass (CF-617) 1/75 APPLICATION FOR PLUMBINGP R1V. IT . y COUNTY OF LOS ANGELES fl �Lj F� DEPARTMENT OF COUNTY ENGINEER REQ© BUILDING AND SAFETY DIVISION MAKE CHECKS PAYABLE TO: BUILDING -�(, 4—P ADDRESS T e \ 4 HARVEY T. BRANDT, COUNTY ENGINEER LOCALITY it {, l FOR APPLICANT TO FILL IN (PRINT OR TYPE) NEAREST C2 CROSS ST. L NUMBER FIXTURE OR ITEM @ FEE 1 WATER CLOSET 2.00 OWNER L f l l��rl� ��• I MAIL r f BATH TUB 2.00 ADDRESS SHOWER 2.00 CITY Imo. 1 f♦� Z TEL. NO. LAVATORY 2.00 CONTRACTOR VhICAiL t Ir- ty- SINK 2.00 ADDRESS IOC E_ C y DISHWASHER 2.00 CITY -I � V �� TEL. NO. • _ c0 CLOTHES WASHER 2.00 STATE LIC ��� SWIMMING POOL RECEPTOR 2.00 LICENSE NO. CLASS DIS ICT NO.GROUP ZONE P OCESSE B LAWN SPRINKLER SYSTEM 2.00 WATER HEATER 2.00 INDUSTRIAL WASTE APPROVAL GAS SYSTEM OUTLETS 2.00 INSPECTION RECORD CD OUTLETS OVER 5 PER SYSTEM .30 O U V W O- N Plan check fee See Reverse PLUMBING PERMIT ISSUING FEE $ 3 00 TOTAL FEE q. C APPROVALS DATE IN9 PE CTOR'9 SIGNATURE Plan check applicant UNDER SLAB WORK Name ROUGH PLUMBING Address GAS PIPING City Tel. No. GAS VENT HOT WATER HEATER I HEREBY ACKNOWLEDGE THAT I 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 PLUMBING. GAS TEST I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR UTILITY CO. NOTIFIED LICENSED AS 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 PROPERTY. FINAL . f SIGNATURE OF PERMITTEE PERMIT VALIDATION CK. M.O. CASH PLAN CHECK VALIDATION CK. M.O. CASH 4 4 q,'.)JUL 15 5 0 5.0 0 arts ,fIiCOMPENSATION DECLARATION DPW I hereby af(itm that that I have a certificate of consent to self Insure, 7MG67 APPLICATION FOR PLUMBING PERMIT or a certificate•of W&ker's Compensation'Insurance, or a certified copy thereof(Sec.3800 Lab C.) � Policy No. — Ampany-,. t - COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV. Certified copy is hereby furnished. r4;30 FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING p WT Certified copy is filed with the ty building inspe ADDRESS depart`me-ntt..t NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date ` ` Applican WATER CLOSET140 NEAREST f CERTIFICATE OF EXEMPTION FRO I RKERS' BATH TUB CROSS ST. COMPENSATION INSURAN / ASSESSOR (This section need not be completed if the work Involved by the SHOWER MAP BOOK PAGES PARCEL permit is for one hundred dollars($100)or less.) LAVATORY OWNER I certify that in the performance of the work for which this permit MAIL Is Issued, I shall not employ any person in any manner so as to SINK ADDRESS ) 1 become subject to the Workers'Compensation Laws. DISWASHER CITY TEL.NO. /1 Date Applicant CLOTHES WASHER CONTRACTOR NOTICE TO APPLICANT: If, after making this Certificate of Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR ADDRESS Lj P provisions of the Labor Code,you must forthwith comply with such provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY TEL.NO. I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER STTE d (commencing with Section 7000)of Division 3 of the Business and LIC. 0 GAS SYSTEM OUTLETS CENSE NO. � CLASS Professions Code,and my license is in full force and effect. V i� Q ?yam ` 5 PER SYSTEM DISTRICT NO. PROCESSED BY License Numb �/�U�'�J Lic.Class � 5.D 6` O � FINAL V ,� DATE — VALIDATION Contractor Data/ /� CL ❑ I am exempt r Sec. ' BY FINAL p ACY:T o s B.&P.C.for this reason �C• :L'`-' i fZ 9-R Date: Plan check fee , LLI_L s .•_•: PLUMBING PERMIT ISSUING FEE$ t i' ' Signature �� ..., ❑ TOTAL FEE O�'�„ TOTAL t�L ��''�' ® '!�� iC Plan check applicant f'NE�Y. 103.'�`'= SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name CHANGE ,i;j I hereby affirm that I am exempt from the Contractor's License Law for the following reason(Section 7031.5, Business and Professions Address Code): fl i0-0. 1 1/11119i ❑ City Tel.No. �_�_ ���. : I,as owner of the property,will do the work and the structure ,r is not Intended or offered for sale(Section 7044, Business 7=114 1 AMIN-20 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 1 correct. I agree to comply with all County ordinances and State We regulating Plumbing, and hereby authorize represent es of this County to er upon the above-mentioned property s cti;npurses. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Per"a Date(""`�