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Home My Public Portal About6040 ROWLAND AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have. a certificate of,consent to self 76A667A /� insure, or a certificate of Workers'Compensation Insurance, I CE 81.7(REV. 10781,,) 4 e or a certified copy thereof(Sec. 3800, Lab. C.) 4 COUNTY OF LOS ANGELES ? BUILDING AND'SAFETY Policy No. Company Certified copy is hereby furnished. ❑ BUILDING FOR APPLICANT TO FILL IN.(PRINT OR TYPE) Certified copy is filed with the county building inspec- ' ADDRESS p 0 ,OGtJ tion department, .NUMBER FIXTURE OR ITEM @ FEE LOCALITY � WATER CLOSET Date. Applicant I . NEAREST If CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS S7. COMPENSATION INSURANCE. (This section need not be completed if the work involved by SHOWER OWNER r the permit is'for.one hundred dollars($100)or less.) l l LAVATORY ADDRESS .4.9c,LIU o.,ax I certify that in the performance of the work for which this � � permit is.issued, I s.ha.11 not employ any p on in any manner SINK CITY �. TEL.NO. so as to become subject to the Worke ompe aws. I DISHWASHER � CONTRACTOR Dateo' 7ZGApplicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, aftmdking is Certificate of ZI. 1 e SWIMMING POOL.RECEPTOR Exemption, you should become subject to the Workers' ? CITY ` TEL.NO.� Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEMK V with comply with such provisions or this permit shall be STATE LIC. deemed revoked. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION I DISTRICT NO. P OCESSED�Y I hereby affirm that I am licensed under provisions of Chapter 9 OAS SYSTEM OUTLETS (commencing with Section 7000)of Division 3 of the BusinessOUTLETS OVER r or and Professions Code,and my license-is in full force and effect. I 5 PER.SYSTEM FINALVALIDATION O 0 License'NumbArK Lc. Class I DATE tt I' FINAL Contract Date 2- BY ❑ I am exempt under Sec I; LU BAP.C. for this reason Plan check fee Date: I' PLUMBING PERMIT ISSUING FEE$ D 0 ► Signature TOTAL FEE so 4 7A 5 A Plan check applicanto a o o 0 SINGLE FAMILY �+t , 5 HOME OWNER-BUILDER'DECLARATION Name 2 0 -o4650 I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and I Address o'n o 1G650 o X Professions Code): I City Tel.-No. ❑ I, as owner of the property, will'do the work and the 12 4—8,3 structure is not intended or offered for sale (Section 7044, Business and Professions Code). li 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 ILender's Address !I I certify that 1 have read this application and state that the I ► i above information is correct. I agree to.comply with all County ordinan and State laws regulating Plumbing, and hereby j ou.th 2 epresentatives of th' County to enter upon the ( ab a entioned pryoprt' s tion purposes. SEE REVERSE FOR.EXPLANATORY LANGUAGE Signet a of er teig Date DOS-17 8•SS PLUMBING APPLICATION FOR LUMBING PERMIT - 1 B3.17 DIVISION OF BUILDING AND SAFETY Deportment of County Engineer County of Los Angeles Bu1LDING WM.J. FOX. COUNTY ENGINEER ADDRESS 6/ CASSATT D.GRIFFIN.SUPT OF BUILDING LOCALITY OR RPLICANT.TO IFNI A NEAREST CROSS ST. OWNER DISTRICT NO. GROUP ONE I READY FFOOR'I.NSSPECTION MAIL /•Q YY ADDRESS INDUSTRIAL CITY TEL.NO.61 WASTE APPROVAL PLUMB INSPECTION RECORD a ADDRESS / .(� CITY T N f0_V ,r LICENS NUMBER TYPE OF FIXTURE OR ITEM FEE WATER CLOSET (TOILET) $ BATH TUB SHOWER LAVATORY (WASH BASIN) KITCHEN SINK DISHWASHER LAUNDRY TUB OR TRAY CLOTHES WASHER TOTAL NO. @ 0.80 APPROVALS DATE INSPECTOR'S SIGNATURE GAS SYSTEM OUTLETS @ 1.00 _ WATER HEATER @ 1.001-7 -o UNDER SLAB WORK PERMIT 7 00 ROUGH PLUMBING S . GAS PIPING TOTAL FEE GAS VENT I HEREBY ACKNOWLEDGE THAT 1 NAVE'READ THIS APPLICATION HOT WATER HEATER AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING FIXTURES PLUMBING. I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR GAS TEST LICENSED AS REQUIRED B LOS ANGELES COUNTY AND STATE OF CALIFORNIA OR THAT 1 M THE LEGAL OWNER OF T'H�.Ea ABO/VE UTILITY CO.NOTIFIED DESCRIBED RESIDENTIAL RO RTY. 'L/ n All E SIGNATUR OF PERM ITTE ` FINAL a�Z-J •;�Gii-�,tl WILLIAM J.FOX.COUNTY ENGINEER VALIDATION R.A.WOOD.CHIEF PLBG.INSPECTOR ;x,4-5 t 6� DEC '2 3 2.00