HomeMy Public PortalAbout6033 ROWLAND AVE_Plumbing__ ctfORKHR3'COMPENSATIONDECLAR)►TION APPLICATION FOR PLUMBING PERMIT
affirm that I have a certMcate of consent to self 7SA667A • T - -
"YfYsu►e„ur a certificate,of Workers',Cbm.pensation Insurance, CE 817(REV.8/86)
or a certified copy thereof(Sec. 3.800, Lab. C.)
COUNTY OF LOS ANGELES DEPT. OF PUBLIC, WORKS
Policy No. Company
Certified.copy is hereby furnished.
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING •�5 ip,�//
Certified copy is,filed with the county building inspec- ADDRESS (f i v0V/
kmw
tion department. NUMBER FIXTURE OR ITEM @ FEE
_ - LocALlnr
Date Appli4ant WATER CLOSET NEAREST
/
a0
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. '
COMPENSATION INSURANCE SHOWER OWNER �-
(This section need not be completed If the work Involved by
the permit is.for one hundred dollars($100)or less.) LAVATORY ADDRESS 6d 3Y ./” , 47V/4(W
I certify that in the performance of the work'for which this �
permit is issued, I shall not employ any person in a y manner SINK Q' .CITY / �/, TEL.No. ,il��
so as to ecom subject•to the W rk rs' ompe tion s. DISHWASHER Y
CONTRACTOR
Date Z 7 pplicant CLOTHES WASHER ADDRESS �� vt ,
NOTICE TO APPLICANT:• I , after aking this Certificate of SWIMMING POOL RECEPTOR `
Exemption,, you shout becom subject to the Workers' CITYI VW
TEL.NO.
Compensation provisio s of th abor Code, you must forth- LAWN SPRINKLER SYSTEM Ida
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER'HEATER LICENSE NO. CLASS.
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PR ED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS.
(commencing with Section 7000)of Division 3 of the,Business OUTLETS OVER `' ^
and Professions Code,and.my license is in full force and effect. 5 PER SYSTEM 'FINAL ,U VALID ION
License Number Lic.Class z_
FIN
ContractorDate BY
I am exempt under Sec.
B.BP.C. for,this reason Plan check fee 271 a q A
Date: PLUMBING PERMIT ISSUING FEE$
Signature # 0 0 a o 0 5
TOTAL FEE J -..o5250
Plan check applicant
SINGLE FAMILY - 0,o 0 5 2 5 0 5
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt•fr'om the Contractor's License Address O'S 2 7 i�-8 7
Law for-the following reason (Section 7031.5, Business and
ro scions 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'coristruction 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. 1 agree to comply with all County
Ordinances and Statelaws regulating Plumbing, and hereby
ut ari repre ntaf(v of this County to enter upon the
4Si -mentio d pro ty for inspection purposes.
�- SEE REVERSE FOR EXPLANATORY LANGUAGE
ature.of Permittee Date'
76MU--CE817&59
APPLICATION FOR PLUMBING PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DMSION BUILDING
JOHN A.LAMBIE. County gnsae�: ADDRESS
CASSATT D. GRIFFIN.Supt o!$uildiag = LOCALITY
a.
FOR APPLICANT TO FILL IN NEAREST
-
NUMBER' FIXTURE OR ITEM CROSS ST.
OWNER
WATER CLOSET
MAIL
RATE TUB ADDRESS
CITY TEL
SHOWER
LAVATORY CONTRACTOR r �•
Suis ADDRESS � f7
Y DISHWASHER CITY TEL NO. —
CONTRACTOR'S STATE 19
LAUNDRY TUB REGISTRATION NO. COUNTY
CLOTHES WASHER DISTRICTNO. GROUP ZONE-- lot
ROCESSEDBY
WATER HEATER
GAS SYSTEM INDUSTRIAL
c WASTE APPROVAL
INSPECTION RECORD
-S f , IRA 1
eg
0 $1.00 PER ITEM I e.
OR FIXTURE $ APPROVALS DATE INSPECTOR'S SIGNATURE
PERMIT $ 2 00 UNDER SLAB WORK
TOTAL FEE ROUGH PLUMBING �•.�� lJ ` %,. .',iw;;ITe,r�.
GAS PIPING
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION GAS VENT
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY .
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING HOT WATER HEATER
PLUMBING.
i HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR PLUMBING FIXTURES
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF GAS TEST
CALIFORNIA OR THA AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENT L ROPERTY. UTILITY CO.NOTIFIED
SIGNATURE
OF PERMITTE c
FINAL Q"22
®� MMATION ROBERT A.WOOD.
CH. M.0. GASB SUPERVISING MECHANICAL.ENG'It
LAf0 4 0 0 1 a; OCT 1. 5 5 A 3.0 0 r"
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