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WORKERS'COMPENSATION DEdLARATIM APPLICATION FOR PLUMBING PERMIT
16eraffirm that I have a certificate of consent to self 20-0026 DPW 6/87
insgre r o certificate of Workers'Compensation Insurance, 76A667A
or a,cdrtified copy thereof(Sec. 3800, Lab. C:) COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS
Policy N8. Company ,
Certified copy is hereby furnished. I +
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING /
Certified copy is filed with the county building ihspec- ADDRESS y M
tion department. NUMBER FIXTURE OR ITEM Q FEE LOCALITY
Date Appligant WATER CLOSET 2 NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATHTUB CROSS ST.
COMPENSATION INSURANCE SHOWER O OWNER 1061
(This section need not be completed if the work Involved by
the permit is for one hundred dollars($100)or less.) LAVATORY MAIL
ADDRESS NJ
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK I CITYb+ TEL.NO..
so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of I� SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers', CITY TEL. NO.
Compensation provisions of'the Labor Code, you must forth-f LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be) STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION I DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 91 GAS SYSTEM OUTLETS D G
(commencing with Section 7000) of Division 3 of the Business! OUTLETS OVER i
and Professions Code,and m license is in full force and effect:' 5 PER SYSTEM
Y FINALVALIDATION ee
DATE "2'[9/
License Number Lic. Class C)
FINAL 0.'
Contractor Date �' I BY Q
❑ I am exempt under Sec. W
B.BP.C. for this reason ® NI
Plan check fee
Date: 5L
PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE 3 �Q
Plan check applicant c
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name r(+y
A:ti•t°a
I hereby affirm that I am exempt from the Contractor's License Address.
Law for the following reason (Section 7031.5, Business and iE7 ��a F—I+
-
Professions Code): City Tel. No. Ert
1E
❑ 1, as owner of the property, will do the work and the t E°1`''
structure is not Intended or offered for sale (Sectionj !I I AL 35 a 0
7044, Business and Professions Code). _
CONSTRUCTION LENDING AGENCY C•�{t •K
I hereby affirm that there is a construction lending agency for # iV�
the performance of the work for which this permit is issu d
(Sec. 3097,Civ. C.).
I
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 I
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above-mentioned pro erty for inspection purposes. I ,
I SEE REVERSE FOR EXPLANATORY LANGUAGE �
Signature of P ittee Date
T
7Ps17 s-sn .-
APPLICATION FOR PLUMBING PERMIT �
DEPARTS OF COUNTYGENGINEER ' -
BUILDING AND SAFETY DIVISION BunbI NG
JOHN A. LAMBIE. COUNTY ENGINEER ADDRESS
WILLIAM A.JENSEN.SUPT OF BUILDING
LOCALITY
FOR APPLICANT TO FILL IN NEAREST
CROSS ST.
NUMBER FIXTURE OR ITEM OWNER
WATER CLOSET Kam
BATH TUB ADDRESS
CITY TEL NO.
' SHOWER
CONTRACTOR
LAVATORY
SIINS ADDRESS
DISHWASHER Q1TY TEL NO.
CONTRACTOR'S STATE
LAUNDRY TUB REGISTRATION NO. COUNTY
CLOTHES WASHER DISTR1 NO. GR�QI� ZONE SED BY
WATER HEATER J J
GAS SYSTEM INDUSTRIAL
WASTE APPROVAL
INSPECTION RECORD
O -
O
' O `
F -
F1 '
Q 31.00 PER 1701
OR FIXTURE $ �� 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 GAS VENT
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING HOT WATER HEATER `
PLUMBING.
I HEREBY CERTIFY THAT I P PERLY ISTER AND/OR PLUMBING FIXTURES
LICENSED AS REQUIRED BY SAN LES llyy TY STATE OF GAS TEST
CALIFORNIA OR THAT 1 HE EGAL W1YE HE ABOVE
DESCRIBED RESIDENTIA RO �.. s UTILITY CO.NOTIFIED
SIGNATURE / ,./4,
OF PERMITTE FINAL Ia ' �/ �} l�!14{►G�° �'
D. - ALIDATION ROBERT A.. ISob, '
M.O. CASE SUPERVISING MECHANICAL ENG-It
s4 0 DEC ? p 3.0 0
7'SA667 17 H-Ho 10 APPLICATION FOR PERMIT
DEPARTMENT OF BUILDING AND.SAFETY •=`
COUNTY OF LOS ANGELES PLUMBING 1
WILLIAM J. FOX. CHIEF ENGINEER
FOR APPLICANT TO FILL IN DISTRIrO. GROUP I ZONE PERMITNO.
PLUMBER WINTERBOTTOM BROS. INC. b�3�SSU90
BROS., RECEIVED BY READY FOR DATE ISSUED
FIRST INSPECTION
ADDRESS 1112 WESTM^N I - AlV%_' 7dG'o-�"
ALI I r=rr�����1 BUILDING &71'
CITY TEL. NO.' ADDRESS
COUNTY "LOCALITY
LICENSE NO. r EXPIRES
His NEAREST .
PERMIT FEES CROSS ST. aw, 1 I: es 0 n
OWNER Maom•n 1 ,.n+ n
NUMBER 'TYPE OF FIXTURE OR ITEM FEE ,d,, •.a,..,.
WATER CLOSET (TOILET) ® 0.50 S r
ADDRESS MAIL '461,
I_ tlfl C� A
lm
w.
BATH TUB ® 0.50 CITY A ng n TEL. NO.
SHOWER Q 0.50 w 1 HEREBY ACKNOWLEDGE THAT 1 HAVE •READ THIS
LAVATORY (WASH BASIN) O.SO 'APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND
-AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND
"�- STATE•LAWS REGULATING PLUMBING.
KITCHEN SINK A 0.50 wn I CERTIFY THAT I POSSESS THE ABOVE VALID LOS
LAUNDRY TUB OR TRAY ® 0.50 �� ANGE COON LISE. OR M THE LEGAL OWNER
OF IA OPE SCRI ED AMOVE.
GAS SYSTEM `3OUTLETS @ 0.50 I SI R
WATER HEATER Q O.50PERMI
v^
SLOP SINK @ 0.50 INSPECTION RECORD
FLOOR SINK @ 0.50
FLOOR DRAIN 0 0.50
DISHWASHER Q 0.961
DRINKING FOUNTAIN A 0.50
URINAL ® 0.50 I ��n S l ejAnM P)E L—C W 10 j< Q
HOUSE SEWER @ 0.50 Z
MISCELLANEOUS UI
0
I
1
APPROVALS
DATE INSPECTOR'S NAME
;ROUGH PLUMBING .A c t_ \- (71 `:�•✓
GAS PIPING
'GAS VENT d+ I er
CESSPOOL ® 1.00I CESSPOOL
SEPTIC TANK: SEPTIC-TANK
DRAIN ( ) PIT ( ) Q 1.00 SEWER
PERMIT 1,00 GAS TEST 4 Z �iL6G't�
UTILITY CO. NOTIFIED 04z)
TOTAL FEE I $ II
'FINAL �