HomeMy Public PortalAbout5620 ROSEMEAD BLVD_Plumbing__ MM67--CEBI7-8-58
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' APPLICAT'ION. FOR PLUMBING PER 1
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
ISAT .F ��� iADDRESS
CATDGA W SSgpof Buildng
LOCALITY
FOR APPLICANT TO FILL IN NEAREST
NUMBER FIXTURE OR ITEM CROSS ST
WATER CLOSET OWNER
P
BATH TOB ADDRESS {1
SHOWER CITY ZIA TEL. N P'
LAVATORY CONTAACTO
SINK ADDRESS
DLNiWAS8E8 CITY TEL.NO:. —Q b
TUB CO CTOA'S p P STATE
LRUNDRY BEGISTAATION.NO. (0 d COUNTY .p
CLOTHES WASHER 'DISTR13NO GROUP I ZONE D BY
WATER HEATER . Cy/ C�
GAS SYSTEM WASTE WASTE APPROVAL
INSPECTION RECORD
T r' 7- I IM,1: '/iV T F
APPROVALS
08 F nmREE $
R ITEM DATE INSPECTOR'S SIGNATURE
UNDER SLAB WORK Q
PERMIT $ 2 00 ROUGH PLUMBING
TOTAL FEE 8 �� GAS PIPING
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION GAS VENT
AND STATE'THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY HOT WATER HEATER
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING. PLUMBING FIXTURES
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR GAS TEST 9- 61
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE UTILITY CO.NOTIFIED
DESCRIBED RESIDENTIAL PROPERTY.
SIGNATURE ° i FINAL
OF PERMITTE
ROBERT A.WOOD.
®p - TALEDATION SUPERVISING MECHANICAL ENG'R
4/
K.
J M.O. CASH
!r.�o4039 .1% 17 5 D 10.00 ".
WORKERS'COMPENSATION DECLARATION I APPLICATION FOR PLUMBING PERMIT
I heP$by affirm that I have a certificate of consentlto self 76A667A I
insure, or a certificate of Workers'Compensation Insurance, CE 817(REV. 10/81)
ora Fied copy thereof(Sec. 3 P, Lab. C.)
Poli1 1 5'om a
E] Certified
Ltd IBJ�� COUNTY OF LOS ANGELES ( BUILDING AND SAFETY
P
Certified copy is hereby furnishe . 4-;-i tc-
FOR APPLICANT TO FILL IN(PRINT OR TYPE) I BUILDING
e Certified copy is filed with the county building inspec- ADDRESS s6 2,U S, 74
tion department. r NUMBER FIXTURE OR ITEM @ FEEyi
LITY '11y
Date r�r l7- Appligant r WATER CLOSET I
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB I CROSS ST.
COMPENSATION INSURANCE
OWNER
(This section need not be completed if the work involved by SHOWER i
MAIL
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS S5 d R47 6 A"L 0 Al •ice
1 certify that in the performance of the work for which this
permit is issued,I shall not employ any person in any manner SINK i CITY TEL.NO.
so as to become subject to the Workers'Compensation Laws. DISHWASHER CONTRACT qL r l /
r /
Date '�" Applicant CLOTHES WASHER .�
NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS-71:,t" �tJ _ )� d--
Exemption,
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY dAJ
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATELIC. C-?�
deemed revoked. WATER HEATER LICENSE NO3- 3 CLASS 92
LICENSED CONTRACTORS DECLARATION DISTRICT NO.r/ 7ED BY
I hereby affirm that I am licensed under provisions of Chapter 9 ! GAS SYSTEM OUTLETS y
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER 0
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINA
�-(J VALID TION D.
/ >'
u' DATEd
License Numbet!6Z lip 3� Lic. Class G- ?l Q
FINA U
Contrac • Date a,'�7 BY IL PZ
❑ I am exempt under S
B.&P.C. for•this reason
Date: Plan check fee PooN
PLUMBING PERMIT ISSUING FEE$ �J z
Signature e_
TOTAL FEE (� ;94834A
SINGLE FAMILY Plan check applicant # o o,o o 0 5
HOME OWNER-BUILDER DECLARATION Name 0 o-1 650
1 hereby affirm that I am exempt from the Contractor's License Address Low for the following reason (Section 7031.5, Business and 'o o o-1 6505
Professions Code): City Tel. No.
❑ I, as owner of the property, will do the work and the 0617-86
structure is not intended or offered for sale (Section S
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 inspectiori purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
2a'I. �� 17- kl
S
Signature o Permittee —TDate