HomeMy Public PortalAbout6202 PRIMROSE AVE_Plumbing__ _ ` •`WORKER'S COMPENSATI6NDECLARATION8t>00LSDPW 9f5,9 , AppLICATION FOR PLUMBING PERMIT
I fiereby,affirm that•I have a certificate of consent to self insure, 78A687A
or a certificate of Worker's Compensation Insurance, or a certified
copy thereof(Sec.3500 Lab.C.) �J
/1/ COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV.
Policy No. Company
❑ Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING !�ja,
❑ Certified copy is filed with the county bui ing ins Ion ADDRESS •_ `�
department. NUMBER FIXTURE OR ITEM FEE
LOCALITY �
Date Applicant AW— .0– WATER CLOSET NEAREST
CROSS ST.
CERTIFICATE OF EXEM ION OM WO ERS' BATH TUB
COMPENSATION
UR
ASSESSOR �� PAGE D�� PARCEL
(This section need not be completed if the wor Involved by the SHOWER MAP BOOK
permit is for one hundred dollars($100)or less.) I LAVATORY OWNER Ce F,
I certify that in the performance of the work for which this permit MAIL �7
is issued, I shall not employ any person in any manner so as toSINK ,�� ADDRESS v
become subject to the Workers'Compensation Laws.
DISWASHER CITYTEL.NO.
Date Applicant CLOTHES WASHER CONTRACTOR / q
NOTICE TO APPLICANT: If, after making this Certificate of &S/ /Uf� V`g
Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR ADDRESS
provisions of the Labor Code,you must forthwith comply with such
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION CITY TEL.NO. d
I hereby affirm that I am licensed under provisions of Chapter 9 / WATER HEATER STATE /►�/ e
(commencing with Section 7000)of Division 3 of the Business and GAS SYSTEM OUTLETS LICENSE NO. G Z��d (/ CLASS V
Professions Code,and my license is in full force and effect.
OUTLETS OVER DISTRICT NO. PROCESSED BY IM
/ �p 5 PER SYSTEM OC
License Number) Z Lic.Classy eJ !r
U
DATE j._ N VALIDATION a
Contractor
❑ FINAL
I am exempt under Sec. BY
B.&P.C.for this reason
Plan check fee
Date:
Signature PLUMBING PERMIT ISSUING FEE$
El 3303 FEE Q Q 3303 150 a 0 i
SINGLE FAMILY C
Plan check applicant i= Y -r-0,
• �'
DECLARATIO
OME
I hereby affirmFthat I am exempt lfromRthe Contractor's License Law Name TOTAL -150 00
for the following reason(Section 7031.5, Business and Professions Address r. V it r�
Code): CHECK 1~13 n 1313
City Tel.Na.
❑ I,as owner of the property,will do the work and the structure CH1=iNGE .00
is not Intended or offered for sale(Section 7044, Business
and Professions Code). ,
CONSTRUCTION LENDING AGENCY 60130-1_;SIJ 1 11/ 7/ft
I hereby affirm that there Is a construction lending agency for the 7591 1 PM 12 15
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 thlq.,ICounty to enter upon the above-mentioned
property for' to rposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
lure Of ermittee Dake
sNMIn IF 0-60 a APPLLICIRTMN FOS Mar
DEPART T L
COIIpTr OFF Los OS A�Gffi.88
G AND Sl�iFB'iR
VVILLIAM J. I . CHIEF ENGINEER PLUMBING
FOR APPLICANT TO FILL IN DISTRI70- GROUP I ZONE PERMITNO.
PLUMBER
T7'oAA BROS., INC. RECEI ED BY READY FOR �DATE IMBUED
`
wDDaEa A AVE. L \l FIRBT INSPEerlow 74 ` -k 1
CITY TEL. NO.
ADDRESS 62 ; PR Itmoss Avm•
COUNTY LIC I I I5 IRUR T)Q"m LOCALITY
NEAREST T1slaFLB CITY F+LVD■
PITT Fm Clava NT.
NYNBiR 'lYPN OR PI=7YIR OR YRY FEE
OWNER ME= LAND CD•
MAIL .6I? EO Llea Om Avc.
WATER CLOS (TOILET) 0.00 • 50 ADDRESS
BATH TUN a 0.50 1 SO CITY AROAD 1 A o CAL 1 F• `No.
SHOWER G 0.00 1 50 1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIN
LAVATORY WASH BASIN O.BO 50 APPLICATION AND STATE THAT THE ABOVE IN CORRECT AND
AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND
KITCHEN SINK a O.NO so STATE LAWS REGULATING PLUMBING.
1 CERTIFY•TNT 1 POaEa THE ABOVE VALID LOS
LAUNDRY TUB OR THAT 0.50 . OR T�� CO IC N6 OR 1 M THE LEGAL OWNER
GAS SYST� OU 0.001 51D �� RIB
SI 'm,
WATER HEATER 0.50 SO PERMI
SLOP SINK 0.00 MBF=Cw ROOM
FLOOR SINK O.BO
FLOOR DRAIN 0.50
DISHWASHER 0.80
DRINKING FOUNTAIN 0.80 E
URINAL 0.50 J
HOUSE NEWER 0.50 Z
MISCELLANEOUS _ (�
.1 1 e, Ci F, PL-big
O
..
o lt h afire
YCST &V APPROVALS
DATZ lmmnc Comm SANS
ROUGH PLUMBING
GAS PIPING
GAS VENT -,L
CaSFOOL 1,00 CESSPOOL
BEPTIC TANK: SEPTIC TANK
• DRAIN ( ) PIT ( ) e 1.Do NEWER
PERMIT 1,00 au TEST F INRL.
TOTAL FEE r3l 00
UTILITY CO. NOTIFIED
FINAL r all W- L44 rw