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7BA607-CES1710-60
APPLICATION FOR PLUMBING PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDINCAND SAFETY DIVISION BUILDING
JOHN A. MBIE. COUNTY ENGINEER ADDRESS ,3 e
WILLIAM A. JEN8EN, BUP'T OF BUILDING LOCALITY `
FOR APPLICANT TO FILL IN NEAREST c'
CROSS ST. /
NUMBER FIXTURE OR ITEM
OWNER
WATER CLOSET MAIL
BATH TUB ADDRESS 'op
CITY TEL
NO.
SHOWER
LAVATORY s
/ CONTRACTOR
'
SINS ADDRESS
1Z74 457,o9A"-
DISHWASHER CITY TEL.NO. _ Z.?di
CONTRA R'S STATE
LAUNDRY TUB REGISTRATION NO. COUNTY
CLOTHES WASHER ��2 DISTRICT HO. ROUPZOO E�SSED BY
E WATER HEATER �G 19--V I J
GAS SYSTEM MDUSTRLUAL
WASTE APPROVAL
c a •e RgSPRCTION RECORD d
O
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oo
Lllool-
13WMR ITEM I
OR FIXTURE $ APPROVALS DATE INSPECTOR'S SIGNATURE
PERMIT$ 2 00 UNDER SLAB WORK A III I� , /. J,n_,
TOTAL E� ROUGH PLUMBING /U r 1
Y
437
GAS PIPING
I HEREBY ACKNOWLEDGE THAT 1 HAVE .READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY GAS VENT '
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING. HOT WATER HEATER
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR PLUMBING FIXTURES // ,., n i A
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF GAS TEST 7''J ✓ �' A -
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE /
DESCRIBED RESIDENTIAL UTILITY CO.NOTIFIED A V
SIGNATURE r
OF PERMITTEEFINAL J .,,J f �.
' ATION ROBERT A. WOOD '
cK. M.o. CASH SUPERVISING MECHANICAL ENG'R
;O0 7 2 4t2 SEP2- 6 5 D 1 1.25- a
VIM667 27 5-50 APPLICATION FOR PERMIT
-DEPARTMENT OF BUILDING AND SAFETY
COUNTY OF LOS ANGELES P L lam' N G
WILLIAM J. FOX, CHIEF ENGINEER
FOR APPLICANT TO FILL IN DISTRICT GROUP ZONE PERMIT NO.
_ y I ° 1361/
PLUMBER ! �^= RECEIVE D BY READY FOR DATE ISSUED
FIRST INSPECTION
ADDRESS 'r , ..
Lon
BUILDING
r f j.t- II T ADDRESS ! L , I w 1.
CITY < TEL. NO. , .: C tee �
e'i
COUNTY
LICENSE NO. F G+ ^. EXPIRES ':' R I V E, LOCALITY
NEAREST �''i. •; r^, '
PERMIT FEES CROSS ST. : t
NUMBER TYPE OF FIXTURE OR ITEM FEE OWNER
MAIL
WATER CLOSET (TOILET) @ 0.50 S ADDRESS -
BATHTUB. 0.50 CITY i
- - � -- -- - -- -. TEL. NO.
SHOWER 0.50 1 HEREBY ACKNOWLEDGE THAT. I HAVE READ THIS
LAVATORY (WASH BASIN) @ O.SG APPLICATION AND STATE THAT THE ABOVE'IS CORRECT AND
AGREE TO COMPLY WITH ALL COUNTY ORDINANCES .AND
KITCHEN SINK Q 0..50 STATE LAWS REGULATING PLUMBING.
I CERTIFY THAT 1 POSSESS THE ABOVE VALID LOS
.--LAUNDRY TUB OR TRAY . @ 0.50 ANGELES COUNTY LICENSE, OR 1 AM THE LEGAL OWNER
OF THE RESIDENTIAL P.ROPERTY'DESCRIBED ABOVE.
GAS SYSTEM OUTLETS @ 0.50 j'• F
SIGNATURE OF
WATER HEATER 0.50 PERMITTEE ` I"� •1• ' -
SLOP SINK @ 0.90 INSPFCTIOI� RECORD
FLOOR SINK Q O.SO
FLOOR DRAIN 0.50
DISHWASHER ® 0.50
DRINKING FOUNTAIN 0.50
.URINAL @ 0.50 „J
HOUSESEWER @ 0.50 z
MISCELLANEOUS U�
E
0
APPROVALS
DATE INSPECTOR'S NAME
ROUGH PLUMBING
GAS PIPING
GAS VENT
CESSPOOL Q 1.00 CESSPOOL
SEPTIC TANK: SEPTIC TANK
DRAIN ( ) PIT ( ) Q 1.00 SEWER
PERMIT . 1.00 GAS TEST
TOTAL FEE
UTILITY CO. NOTIFIED
ffi / �� ..
FINAL
WORKERS;,CO*, PEtJSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I herebyt;affirrit that.I have a certificote of consent to self 78A687A I I
'insure, or a certifisafe'of Workers'Compensaion Insurance, CE 817(REV.8/88) LLLIII
or a certified copy thereof(Sec. 3800, Lab. C.;
Polis No. COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
❑ y Company C`acualtY t K.
Certified copy is hereby furnished. BUILDING
FOR APPLICANT TO FILL IN(PRINT OR TYPE)
Certified copy is filed with.the county building inspec- ADDRESS 6039. PYll1lrOSe
tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Temple City, ,
Date?-7d—Q7 Appli4ant Qj= M Dll,rr WATER CLOSET ® NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS, BATH TUB CROSS ST. '
COMPENSATION INSURANCE OWNER
(This section need not be completed If the work Involved by SHOWER V.I.P. BLlllder5.
the permit is for one hundred dollar $100 or less. .� MAIL 205 San Gabriel Blvd.
p ( ) ) LAVATORY ADDRESS
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK --- CITY San Gabriel TEL.No309-9333
.so as to become subject to the Workers'Compensation Laws. DISHWASHER >
CONTRACTOR oWen BY1US. P11II11blI1 r IriC. •
Date Applicant [CLOTHES WASHER ADDRESS •4265 N.' Baldwin Ave..
NOTICE. TO APPLICANT: If, after making this Certificate of
Exemtion, jou should become subject to the Workers' SWIMMING POOL RECEPTOR
P Y I CITY El Monte TEL.NO. 443-0078
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such. provisions or this permit shall be STATE LIC.
deemed revoked;, WATER HEATER / ,� LICENSE NO. 231 741 CLASS .C36-20
LICENSED CONTRACTORS DECLARATION rc� DISTRICT NO. , SSED BY
GAS SYSTEM OUTLETS
I hereby affirm that I am licensed under provisions of'Chapter 9 O /Cf�
(commencing with'Section 7000)of Division.3 of the Business OUTLETS OVER
and Professions Code,,and my license is in full force and effect. 5 PER SYSTEM FIAL i VALIDATION
D
License Number 231 741 Lic. Class C36=20
FINA
ContractorOwPn BMs- PJ2g Date 2-24-87 BY
0 I am exempt under Sec. g
- - a
B:BP.C..for this reason
Plan check fee
Date:
PLUMBING.PERMIT ISSUING FEE$
Signature. :0 6 5 9.8 A
TOTAL FEE
# 0000.05
Plan check applicant
SINGLE FAMILY o o 8 8 5 O
HOME OWNER-BUILDER DECLARATION ' Name
I hereby off irm that I am exempt.from the Contractor's License Address o o -,8a5 0 5
Law for-the following reason (Section 7031.5, Business and
Professions Code): City ,Tel. No. 0227d--87
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
.1 certify that I have read this application and state that the ► r
above Information is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing,•and hereby
Whorize representatives of this County to enter upon the
entioned pro arty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
ature of Permittee Date