HomeMy Public PortalAbout5519 SARA MAR LN_Plumbing__ faAaaT APPLICATION -FOR PLUMBING PERMIT 7
Dos n:aDIMON OF BUILDING AND SAFETY 1
Depmimmt of Comte Englnw
Comfy of Loa Angors
WM J FOX, COUNTY ENGINEER BUILDING
ADDRESS
CASSATT D GRIFFIN BUP T of SUILDiIq
LOCALITY
B MCANT TO FILL IN NEAREST
jz
OWNER DISTRICT N GRQUP ZONE ■"DY roB INSP&CTION
MAIL iT
ADDRESS
INDUSTRIAL
CITY WASTE APPROVAL
PLUMBER �f/9G INSPF=ON RECORD
ADDREBS a 11 23 11T A�•
CITY T NO J Z
I LICENSE NO
NUMB" TYPE OP FIKTURE OR ITEM PEE
WATER CLOSET (TOILET) S
-BATHTUB___ Q
SHOWER
LAVATORY (WASHBASIN)
KITCHEN BINK V
DISHWASHER _
LAUNDRY TUB OR TRAY _
CLOTHES WASHER
TOTAL NO a O Bo APPROVALS
DATE INSPECTOR S SIGNATURE
6A6 SYSTEM-2-OUTLETS ® 100 Q
WATER HEATER 100 OO UNDER BLAB WORK
ROUGH PLUMBING
PERMIT • 1 OO OAS PIPING
TOTAL FEE O GAB VENT
I HEREBY ACKNOWLEDGE THAT I HAVE 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 _
1 HERESY CERTIFY AM OPENLY REGISTERE ANO R GAS TEST
LICENSED AS REOED OS GELES CBI TY AN UTILITYCO NOTIFIED S-I SSL
CALIFORNIA OR HAT T LEGAL WN
DESCRIBED RES ENT] R TY
SIGNATURE
OF PERMITT FINAL S
WILLIAM J FOX. COUNTY ENGINEER VALIDAnON <
&9577„' NQV 1 3 780
/ DEPUTY
m r t•'/ (
WORKERShat I have a ION DECLARATION cat APPLICATION FOR PLUMBING PERMIT
1 herebyaffirm that I have a certificate of consent to salt es av a�eo)
insure, or a certificate of Workers'Compensation Insurance or
a certified copy thereof(Sec 3800,Leb C)
COUNTY OF LOS ANGELES �{� BUILDING AND SAFETY,
Policy No Company VJ
❑ Certified copy is hereby furnished FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
❑ SS/J S.r.a /Fe-s ,✓
Certified copy u filed with the county building inspection NUMBER FIXTURE OR ITEM • FEE ADDRESS
department LOCALITY ,
Date Applicant WATER CLOSET NEAREST
BATH TUB CROSS ST
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE SHOWER OWNER
(Titin section need not be comppleted 1f the work urvolved LAVATORY ADDRESS
by the permit a for one hundred dollars (5100) or lea) Y
SINK CITY ,r TEL NO Z�S Jy 00-
I certify that in the performance of the work for which this DISHWASHER , U
Permit is issued, I shall not employ any person in any manner CONTRACTOR
so as to become subject to the Workers' Compensation Laws CLOTHES WASHER - o0
ADDRESS U
Date Applicant SWIMMING POOL RECEPTOR
NOTICE TO APPLICANT If after making this Certificate of CITYL NO W
Exemption, you should become subject to the Workers LAWN SPRINKLER SYSTEM LIC
STATE LIC 4:41
Compensation provisions of the Labor Code, you must forthLICENSE NO Cl--ASS
Z
with comply with such provisions or this permit shall be WATER HEATER
deemed revoked GAS SYSTEM OUTLETSJA�Jn'�aTRIC ANO P OC ED BY
LICENSED CONTRACTORS DECLARATION OUTLETS OVER `� • ��
I hereby affirm that I am licensed under provisions of Chapter 15 PER SYSTEM
9 (commencing with Section 7000)of Division 3 of the Bust FINA
DATE LIDAT N
ness and Professions Code, and my license is in full force and
effect
FI L
License Number Lic Class-
Contractor-
lassContractor Date
❑ I am exempt from the licensing requirements as I am a Plan Check fee I I '
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$ 11
acting in my professional capacity (Section 7051 Bus
loess and Professions Code) - TOTAL FEE D
Lic or Reg No Date Plan cheek applicant
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that 1 exempt from the Contractor's Address Rw M 9 a 2 Q
License Law for the owing reaso (Section 7031 5, Bust City Tel No Z&7 1 f� • -,* a • 5
ness and Profnstons de�
�--1, as owner of a property, exclinively contracting 2 • e 1 a 0 0
with Ircenud m actors to construct the project
(Section 7044 Business,and Professions Code) • • • ) 0 p 0 TS
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(See 3097 Civ C)
Lender's Name
Lender's Address
I certify that 1 have read this application and state that the
above information is correct I agree to comply with all County SEE REVERSE FOR EXPLANATORY LANGUAGE -
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above mentioned pr Perry r inspection purposes
19�f/ A"C
Signature ermittee Date