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MrA MKETU OF OOUT= EN(ONEM
PLUMBING 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
OOUNW OF LOS ANGELES BUILDING
WILLIAM J- FOX, CouHry EHOII+cEw ,ADDRESS 00
FOR APPLICANT TO F LL IN CALiTY . G�
BUILDING NEAREST /J
ADDRESS CROSS ST. V
DISTRICT N0. S+UPZONE/1 PERI•JI y0
LOCALITY �D'
EAREST ✓�J
PRO86 ST. RE C ED Rraty hr IarhttlM DATY IfflgMD
OWNER
MAIL INOU 1
ADDRESS WASTE APPAMVAL
Q
CITY TEL NQ INSPECTION RECORD J�
PLUMBER v
ADDRESS
CITY TEL NO.LL
LICENSE NO. I 1� ❑O UNTY J
PERMIT FEES i
4LIMN[R TYPE Or FDCTIMIC OR IT[M FQ
WATER OLOSET(TOIL ! ao $
BATH TUB ! Lm
SHOWER ! S." .
LAVATORY(WASH BASIN) 9.811
KITCHEN SINK ! S M
LAUNDRY TUB OR TRAY f sm
SLOP SINK ! I."
FLOOR SINK ! am
FLOOR DRAIN ! Lao
DISHWASHER
DRINKING FOUNTAIN ! O.SS
URINAL ! sm
GAS SYSTE■ OUTLETS ! Im
HATER HEATER !Rl
m
MISCELLANEOUS
ok APPROVALS
DATE INSPECTOR'S W KATU
UNDER SLAB WORK o
PR(1T1 00 ROUGH PLUMBING
TOTAL FrJ GAS PIPING
I HEREBY ACKNOWLEDGE THAT I HD THIS APPLI-
GAS VENT
CATION AND STATE THAT THE ABOVE T AND AGREE HOT WATER HEATER
TO COMPLY WITH ALL COUNTY ORDINASTATE LAWSREGULATING PLUMBING. PLUMBING FIXTURES - OIIHEREBY CERTIFY THAT I AM REGISTERED
AHD/OR LICENSED AS REQUIRED BYELES COUNTY GAS TEST
AND STATE OF CALIFORNIA OR THAT LEGAL OWN-
EROF THE ABOVE DESCRIBED RESIDESTY. UTILITY CO.NOTIFIED
SIGNATURE
OF PERNMEE
FINA
TdAMT DBS 1T
Cab Is-sa .
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7M667-CID 1-74-57
APPLICATION FbWPLUMBI.NG PERMIT 1
COUNTY OF LM AtfQELffi
DEPARTNIEN7 OF COUNTY I:ZfCiIIfEES
011111
BUMbINQ AND SAFETY DIVISION ADDRESS
JOHN A. LAMBIE. COUNTY ENGINEER
A"ATT D. GRIFFIN, SUf'T OF BUILDING LOCALITY E&In 04trNEARESTC
FOR APP CANT T FILL IN 4MOM ST.
NLIMBtR FIXTURE OR ITEM
OWNER _ /moo In m
WATER CLOSET
BATS TUB AN Fab / d o o D /9
SHOWER
LAVATORY CQXTILACTOR
SM ADDEEM
bISHWA;sffi. CITY TEL NO.
LAUNDRY TM CONTRACTORI STATE El
REGMTI ATION NO. COUNTY 0
QATHFFJ3 WSHIM 'i DISTRICT N0. GROUPZ,QNE Pt 1!ADY F"IXfP[CT IOM
WATER HEATED
O-A.SYSTEM INDUSTRIAL
�►sTE AFPRov
913PECTION RD
41 a o 14
f
A"ROVAL3
Sim Pn n7w DATE INSPECTOR'S SIGNATURE
OH ILx-rlu / UNPER SLAf3 WORK
PERMIT s I OO ROUGH PLUMEING
GAS PIPING
TOTAL FEE :2- GAB VENT.
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICXT10N HO'r WATER HEATER
AND STATE THAT THE AWVE 13 CORRECT AND AGREE TO CONKY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING Pl-UMBING FIXTURES
PLUYBINQ.
I HEREBY CERTIrf THAT 1 AY PROPERLY RE491STERFD AND/OR GAS TEST
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNJA OR THAT 1 AY THE LEGAL OWXPR OF THP ABOVE UTILITY CO. NOTWIED
DESCRIBED RESIDENT AL PROPERTY.
EIGNATUFF��E
OPPERMITT EE FINAL
�. VAIID$TION ROBERT A. WOOD,
SUPERVISING MEGHANIr.AI-ENG'R
CK. N.o:
0 678-S JM24 3 A 2.00 P
• , ffiWORKERS'COMPENSATION DECLARATION - APPLICATION_7FORPLUMBING PERMIT
` J )1ereby arm that I helve a.certlflcat�of consent to self 20-QD2E DPW 6/87
I Insure, ofa certificate of Workers' Gompensa?1on Insurance, 7BPtWA
as a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
I
Policy No. Company
7
Certified copy R hereby fumished.
FOR APPLIC1Wr TO FILL IN(PRINT OR TYPE) BUILDING �
Certlflsd copy Is filed with the county building Inspec-
Ilon department. NUMBER FIXTURE OR ITEM FEE LOCALITY
I
Date Appll4ant WATER CLOSET NEA T
CERTIFICATE OF D(EMPTIQN FROM WORKERS' BATfi TUB "bo '
COMPENSAT}ON INSURANCE 344OWER OWNER
(This section rw6d not be completed If the work Irrvolwd by MAIL
the permh Is for one hundred dollars ($100)or less.) LAVATORY ADORES
I certify that In the performance of the work for which this Na
permit Is Issued, I shall not employ any Person In arty manner 54NK TEL
to as to become syblect to the Workers Compensation Laws. DISHWASHER
pllcpnt CLOTHES WASHER ADDRESS
CE APPLICANT: If, after ma this Certtflca of SWIMMING POOL RECEPTOR
Exemption, you should becomesubject to the Workers' CITY Tty
Compensatlon 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 FRATER UCISJM NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PkOCEWIM BY
by a
I herefflm-that}am licensed undeK provblons of Chapter 9 GAS SYSTEM OUTLETS U sJ
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER r
and Professions Code,and my Ikense Is tnfull force and effect. 5 PER SYSTEM FINAL VALIDATION
DATE
License Number _ w� Llc. Class CCU��
FINAL
Contractor Date BY g
1 am exempt under Sec. �+
.B.SP.0 for this reason Plan check fee
Date. PLUMBING PERMIT ISSUING FEE;
Slgriatyre TOTAL FEE
SINGLE FAMILY
Plan check applicant
HOME OWNER-BUILDER DECLARATION Name - 1
I hereby affirm that I am exempt from the Contractoe!lJcense AddirACCT•T
Law for the following reason (Section 7031.5, Business ander 3307 Q.50prgsslons Qode): City Tel. No.
7'J� I, as owner of the property, will do the work and the 1 ITM
structure Is not Intended or offered for sale (Section
7001, Business and Professions Code). TOTAL 40 .50
CONSTRUCTION LENDING AGENCY MCK 40.50-
I hereby affirm that there Is a construction lending agency for tin
the performance of the work for which this permit Is Issued •
(Sec. 3097, CIv. C.�
Lender's Name 000ID-W01 8/23!$9
Lender's Address 'J
I certify that I have read this application and state that the +�47 1 AI11Q .
above Information Is correct. I agree to comply with all County
ordinances and State laws regylating Plumbing, and hereby
authorize repretentptives of this County to enter upon the
entloodd pro Inspection "'f SEE REVERSE FOR EXPLANATORY LANGUAGE
gnature of Permittee Data ,•////