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APPLICATION FOR PLUMBING PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DMSION BUILDING
JOHN A. LAMBIE. COUNTY ENGINEER ADDRESS
WILLIAM A.JENSEN, SUP'T OF BUILDING LOCALITY /
FOR APPLICANT TO FILL IN NEAREST
CROSS ST.
NUMBER FII:TURE OR ITEM EACH FEE
OWNER
WATER CLOSET $1.25 MAIL '
BATH TUB 1.25 ADDRESS
SHOWER 1.25 ITY TEL. NO.
LAVATORY 1.25 J CONTRACTOR _
SINS 1.25 ADDRESS Q
DISHWASHER 1.25 CITY L
LAUNDRY TUB 1.25 CONTRACTOR'S �� STATE ❑
REGISTRATION NO. COUNTY ❑
CLOTHES WASHER 1.25 DISTRICT NO. GROUP ZONE PROCESSED BY
WATER HEATER 1.50
GAS SYSTEM OUTLETS- 1.50 INDUSTRIAL a
WASTE APPROVAL 0
OUTLETS OVERIS PER SYSTEM .30 INSPECTION RECORD U
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APPROVALS DATE INSPECTOR'S SJGNATURE
PERMIT. 5 2 00 UNDER SLAB WORK lip(/, )� A
ROUGH PLUMBING _mw.-f--_/ '
TOTAL FEE' , 1 GAS PIPING 77-- /
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1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION GAS VENT
AND STATE THAT THE ABOVE 18 CORRECT AND AGREE TO COMPLY
WITH ALL
G. COUNTY ORDINANCES AND STATE LAWS REGULATINGPLUMBHOT WATER HEATER
1 HEREBY CERTIFY THA AM PROPERLY REGISTERED AND/OR PLUMBING FIXTURES .�•�•`. j,+,',�,,, ��,.s
LICENSED AS REQUIRED 05 ANGELES COUNTY A STATE OF GAS TEST ,/.{,
CALIFORNIA OR THAT I M HE LEGAL OWNER OF, D INTEND TO
RESIDE IN,THE ABOVE DES IBED RESIDENTIAL RDP v. UTILITY CO.NOTIFIED
Y
SIGNATURE
OF PERMITTEE
FINAL
77" ALIDATION ROBERT A.WOOD
CK.
M.0. CASH SUPERVISING MECHANICAL ENG'R
UL03 0 2 6% AUG 2 4 5 A 1625
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WORKERS'COMPENSATION DESIARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certifica of consent to self 20-0026 DPW 6/87
insure, or a certificate of Workers'Compensation Insurance, 7GA667A ILII
or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No. Company
Certified copy is hereby furnished. BUILDING
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS �V./�VS eTe_
,
`v�
Certified copy is filed with the county building inspec-
tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Date Appligant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. 3v 1(_Tbr-1
COMPENSATION INSURANCEOWNER aop-e
(This section need not be completed If the work Involved by SHOWER ��
the permit is for one hundred dollars 5100 or loss. MAIL
p ( ) ) LAVATORY ADDRESS TZP atQCCc�S !(�V
I certify that in the performance of the work for which this r,
permit is issued,I shall not employ any person in any manner SINK CITY _ /' R'L, TEL.NO.30q 5'3)3
so as to become subject to the Worker 'Compensatio S. DISHWASHER c'
CONTRACTOR &J L ONX-4c77 4_
Date
,pt-30
� pplicant CLOTHES WASHER ADDRESS -7 6. 6.eN10jQ— �tf2
NOTICE TO APPLICANT: If, aft making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers' CITY GjW 7),A� X TEL. NO.$3 �e
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATEGG LIC. Gam. 3(0
deemed revoked. WATER HEATER LICENSE NO. _`M CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS X:rD O
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER O
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL -�� n� VALIDATION C
License Number
Lic. Class 4_3
DATE "�
�A t3` l 1 —1.3 FINAL
Contractor Date BY C
❑ I am exempt under Sec. `f
_ ,53 D 111
B.BP.C. for this reason � Qi
aZ—`1•� Plan check fee
—Date"
PLUMBING PERMIT ISSUING FEE$
Signature Q
TOTAL FEE a (J
SINGLE FAMILY Plan check applicant ew
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License
Address
Law for the following reason (Section 7031.5, Business and
Professions Code): City Tel. No.
❑ 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
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 this County to enter upon the
above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date