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HomeMy Public PortalAbout10253 RANDWICK DR_Plumbing__ WORKERS'COMPENSATION DECLARATION 76AG67A I hereby affirm th.it I have a certificate of consent to self c6 of 7(2-80) APPLICATION FOR PLUMBING PERMIT insure,or a certificate of Workers'Compensation.Insurance,or l �' -e,eert �op�r tgerf(Sec 3800,Lab. `'PoTic COUNTY OF LOS ANGELES DfNG_AND SG�►FETY -PoTic No. CompanR11 G Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDIN Certified copy is filed with the cou ' in ginsaction NUMBER FIXTURE OR ITEM 49 FEE ADDRESS AkA pipbry` WATER CLOSET LOCALITY lApplicent ate� NEAREST BATH TUB CROSS � CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE SHOWER OWNER Yl LAVATORY MAIL (This section need not be completed if the work involved ADDRESS by the permit is (or one hundred dollars ($100) or less.) SINK CITYL.NO. d O I certify that in the performance of the work for which this DISHWASHER U CONTRACTOR permit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. CLOTHES WASHERO ADDRESS Date Applicant SWIMMING POOL RECEPTOR V NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL. tL Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEMSTATE d rn Compensation provisions of the Labor Code,you must forth- LICENSE NO. CLASS with comply with such provisions or this permit shall be WATER HEATER deemed revoked. GAS SYSTEM OUTLETS DISTRICT NO. PR CESSEB BY LICENSED CONTRACTORS DECLARATION OUTLETS OVER 0 I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM 9 (commencing with Section 7000)of Division 3 of the Busi- FINAL ness and Professions Code, and my license is in full force and DATE 0 VALIDATION effect. -._. FINAL' i License Number Lic.Class BY /2i Contractor (byAv / I am exempt from the licensing requirements as I am a Plan check fee licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$ 1 acting in my professional capacity (Section 7051, Bus- iness anda od . TOTAL FEE Lic.or Reg.No. Date Plan check applicant HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's Address License Law for the following reason (Section 7031.5, Busi- City CS, Tel.No. �i 4 3 4,8 A ness and Professions Code): I, as owner of the property, am exclusively contracting # 0 0 0 0 0 with licensed contractors to construct the project (Section 7044,Business and Professions Code). 2 0 0 1 3 O O CONSTRUCTION LENDING AGENCY 0 0 0 1 'Z 0 O I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is 0 3 1 0_e 1 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 SEE REVERSE FOR EXPLANATORY LANGUAGE ordinances and State laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the e-mentioned prop for inspection purposes. , I ti (i{ ignature of Permittee Date Xtl Q 78 AS87-C E#817 10-87 I G, �"Y D� s�ii7L� •rte _ APPLICATION FOR PLUMBING PERMIT COUNTY OF LOS ANGELES DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DMSION BUILDING { S JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS J 1 COLEMAN W. JENKINS. SUPT. OF BUILDING LOCALITY FOR.APPLICANT TO FILL IN(PRINT OR TYPE) IN ROS�ST. NUMBER FIXTURE OR ITEM EACH FEE / L OWNER !!1� WATER CLOSET 1.50 ;'V MAIL I BATH TUB 1.50 Jo ADDRESS i SHOWER 1.50 CITY TEL. NO. 1 LAVATORY11 1.50 �® CONTRACTOR 06 SINK S "IN 0111 1.50 S® ADDRESS I'Z,BCX BLVD DISHWASHER 1.50 CITY L v TEL. NO. CLOTHES WASHER 1.50 STATE LIC LICENSE NO. -2 CLASS SWIMMING POOL RECEPTOR 1.50DISTRICT NO. CROUP ZONE PSR C SED BY LAWN SPRINKLER SYSTEM 2.00 O 8 - / ( 0 WATER HEATER 1.50 INDUSTRIAL V WASTE APPROVAL = CD GAS SYSTEM OUTLETS 1.50 INSPECTION RECORD V OUTLETS OVER 30 d 5 PER SYSTEM ti r� Plan check fee 25% of above. See reverse. PLUMBING PERMIT ISSUING FEE S 2 00 TOTAL FEE © ? APPROVALS DATE INSPECTOR'S SIGNATURE Plan check applicant UNDER SLAB WORK Name ROUGH PLUMBING w Address GAS PIPING GAS VENT CLI Tel. No. HOT WATER HEATER EBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION ATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY PLUMBING FIXTURES LL COUNTY ORDINANCES AND STATE LAWS REGULATING GAS TEST G. EBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR UTILITY CO.NOTIFIED D AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF NIA OR THAT 1 AM THE LEGAL OWNER OF,AND INTEND TO IN,THE ABO EBCRIBED RESIDENTIAL PROPE�R�T/Y FINAL URE � JACK R. ALLEN, SUPERVISING HANICAL ENG'R. RMITTE PERMIT VALIDATION JOAN CASH PLAN CHECK VALIDATION CK. M.O. CASH LNIJo 6 �f 6 0 m UCI 9 5 D 0 ^` /o.�r//L//��•v 78A887-CE#817 5.51. APPLICATION FOR LUMBING P RMIT COUNTY OF LOS ANGELES DUMB= OF COUNTY MGM= B OH•NIA. LAAMB E M ENa�i�xE�N BUILDING /O WILLIAM A. JENSEN, SUPT OF BUILDING A LOCALITY FOR APPLICANT TO FILL IN NEARE SP, NUMBER FIXTURE OR ITEM OWNER WATER CLOSE! MAIL ADDRESS BATH TUB CITY TEL.NO. BROWSE Fl— LAVATORY _ , coNTSAcros a ey �'lumbing CO. � SME ADDRESS ° ee'EWood Fl.- DISHWASHER .� &,, ora TSL.NO. .Ed �— LAUNDRY TDB W ffiSTEATIOCOMN NO. 209432 COD., CLOTHES WASHERDISTRI NO. GROUP ZONE SED BY WATER HEATER ^ d GAS SYSTEM INDUSTRIAL WASTE APPROVAL: INSPECTION RECORD, /9 .,1 lo- N Z 'PER ITEM ® ,� OR FIRTUBE S I �� APPROVAL'S INSPECTQR'S 9I61y4TUR6 PERMIT $ 2 00 UNDER "rCi9'WORK 0AA;i._- � p. TOTAL PEE - ROUGH PLUMBING et fJ .Iey.7( OAS PIPING I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION - D ANSTATE THAT THE ABOV. 9 E IS CORRECT AND AGREE TO COMPLY GAS VENT b` .9 WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING HOT WATER.HEATER' y9` �f �y .7 PLUMBING. y .s9!' I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR PLUMBING FIXTURES LICENSED AS REQUIRED BY LOS,ANGELES COUNTY AND STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE• GAS TEST - DESCRIBED RESIDENTIA, PARTY UTILITY CO.NOTIFIED. SIGNATURE " G1""NAlOF PERMITTE FINAL VALIDATION ROBERT Af WOOD C M.0. CASH SUPERVISING MECHANICAL ENG'R Lh(;o7820:j DEC 4 5. p 1 � 55- .