HomeMy Public PortalAbout5628-5628 1/2-5632-5632 1/2 ROSEMEAD BLVD_Plumbing__ 6A667-CE.#617 5.61•
APPLICATION FOR PLUMBING. PERMIT .
COUNTY OF LOS'ANGELES "
DEPARTMENT 'OF COUNTYENGII�TEER
_BUIY.DIIv AND SAFETY DyVSSION SUaDIXss
JOHN AMB1E, COUNTY ENGINEER nDDRE � Z
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WILLIAM A. JENSEN, SUPT OF BUILDINGzbcmff
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FOR APPLICANT TO F11.4. IN, A SY.
NUMBEA FIXTURE OR ITEM
F WAT88 CLOSEY (7 MAIL' -
ADDRESS 5� D• lJ'. .�l.��- 1 J-
RATH TOS - �t
CIYY• IPi1'drk TEL.,RO. ,,4-.r. C
SHOWER
CONTRACT611.
LAVATORY p.
OINKAD MUIRS
a 'cart- iEL.Ro. ,f I
DISHWASHER
CONTBACYO 'S - - rA
LAZIRDRY TUB BEGISTSATIOR NO.
„CLOTFIEB WASHES- DISTRICT NOS/ GROUP - 'ZONE PROCESSED BY
WATER l=TSR
ndDUSTSI&L
I: GAS SYSTEM WASTE APPROVAL
P�� �� ✓:: 1 >ri MCTIOR RECORD. 9•
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104
OR Funli B S' I /! „,�' Y•' APPROVALS' AT y. INSPECTOR'S SIGNATURIt
PERMIT $ 2 00 UNDER-SLAB WORK 7,^' pS� "`/G'"f/.•t
ROUGH PLUMBING 6,,-;;;=%ri+ 9��. Iw
p p
TOTAL FEE ,dXS PIPING -
•1 HEREBY-ACKNOWLEDGE THAT'1'HAVE READ THIS'APPLICATION • ^ ,
AND STATE THAT THE ABOVE IS CORRECT-AND AGREE TO COMPLY GAS VENT
WITH ALL COUNTY ORDINANCES AND-STATE 'LAWS REGULATING HOT WATER HEATER
.PLUMBING.
I H91iBBY CERTIFTHAT I AM. PROPERLY RE.6{ISTERED AND/OR PLUMBING"FIXTURES
LICENSED AS REQUY.IRED. BY LOS,ANGELES COUNTY AND STATE OF 'GAS TEST '
CALIFORNIA OR THAT-I AM THE LEGAL OWN R OF THE ABOVE _GAS
�! DESCRIBED RESIDENTIAL PROPERTY. - UTILITY.CO.NOTIFIED _
SIGNATURE
1
OP PERMIrrEv FINAL
AMATION. ROBERT A.WOOD
CK. M.'O. :.." CASH SUPERVISING MECHANICAL ENG'R;
LA
Co
6. 7 .2% .m1.6 5 D` . 13,251-1
.
AhML J
ION
WORKER'S I have
a certificate
of consent to M667 DPW 9189 APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self Insure, 78A557A
or a certificate of Worker's Compensation Insurance, or a certified
copy theFeo (S X800 Lab.C
PolicyNo U om any S/I4TZ— �(- /Vo COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV.
Certified copy Is hereby furnished. BUILDING j �J77 }� '` f1
FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS �7�/(` V ti If
❑ Certified copy is filed with the county building inspection
department. NUMBER FIXTURE OR ITEM FEE
1� _�s ^J� LOCALITY
Data Applicant Y '� - WATER CLOSET L/ NEAREST ,
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST.
COMPENSATION INSURANCE BATH TUB
ASSESSOR
(This section need not be completed if the work Involved by the SHOWER MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) //��OWNERkP WA
I certify that in the performance of the work for which this permit LAVATORY Cr a
is issued, I shall not employ any person In any manner so as to SINK ADDRESS 62 It �'��i yL VI-7
become subject to the Workers'Compensation Laws.
DISWASHER CITY ` Ct TEL.NO. --xe
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOR J Yo(/U-4 GyNs�] UGT7rJ�
Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR �j
provisions of the Labor Code,you must forthwith comply with such ADDRESS a•f '4J.RbS-e-W;4J>
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM �I
LICENSED CONTRACTORS DECLARATION CITY P 0 &1-1�b TEL-}JO. �� >
I hereby affirm that I em licensed under provisions of Chapter 9 WATER HEATER STATE �7 LIC. IL
d•1
(commencing with Section 7000)of Division 3 of the Business and GAS SYSTEM OUTLETS LICENSE NO. 3OQ —o CLIA$,,, ,C
Professions Code,and my license is In full force and effect. 7v
Q OUTLETS OVER DISTRICT NO. PRE3P.0-�.ED BY
License Number 3a u s~0 5 PER SYSTEM �� � „ i ��M- C
Lic.Class c7. ��� � ,,�-,.
FINAL Gn•USr,��ptTrtaU ATE �,� - VAL1�R-TION °'" " �
rtz'��j y�ewuu�b a ate— L f z" ry `la
Contractor Date r—�•. :1 e
ElFINAL !;p i-- -�
I am exempt under Sec. BYkj% CHIA vG ,i-Itr
B.&P.C.for this reason
Plan check fee
Date: pop. C f1?�(-010-1 i 1 f'%LI'/F
PLUMBING PERMIT ISSUING FEE$
Signature r t Ia 014 :21.
,} o••`�t'
❑ TOTAL FEE f `
SINGLE FAMILY Plan check applicant ,
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Law
for the following reason(Section 7031.5, Business and Professions Address
Code):
❑ I 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
prop y for Inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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