HomeMy Public PortalAbout4967-4969 SERENO DR_Plumbing__ 76,667A .1
` APP ICATION FOR PLUMBING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN(PRINT OR TYPE( BUILDING
DDRE
ADDRESS fN � ��
NUMBER FIXTURE OR ITEM 9 FEE
LOCALITY 1
WATER CLOSET
NEAREST
BATHTUB CROSSST _/GL
SHOWER OWNER E
LAVATORY MAIL
ADDRESS
SINK CITY ���/ ✓�i A—::, TEL N020 ;?1119
DISHWASHER CONTRACTOR
CLOTHES WASHER ADDRESS
SWIMMING POOL RECEPTOR
CITY TEL NO
LAWN SPRINKLER SYSTEM
STATE LIC
WATER HEATER LICENSE NO CLASS
GLAJJSATURE
S SYSTEM OUTLETS APPROVALS DATE INSPECTOR S SIGN
SOPER SYSTEM UNDER SLAB WORK y
.HOUGH PLUMBING A
GAS PIPING V
fF
NT
ATER HEATER Q
NG FIXTURES E�LLj
ST }Q
Plan check fee CO NOTIFIED Z
PLUMBING PERMIT ISSUING FEE$
TOTAL FEE Plan check applicant N CHECK VALIDATION
Nome
Address 0 4 a 9 n
City Tel No }� C
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE EF N - 5
THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES
AND STATE LAWS REGULATING PLUMBING PERMIT VALIDATION 2 . . 1 000
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/ON LICENSED AS
REQUIRED BY LOS ANGELES COUNTY AND STATE OF CALIFORNIA OR THAT I AM THE . . . , 0 000
LEGAL OWNER OF AND INTEND T RESIDE IN THE ABOVE DESCRIBED RESIDENTIAL
PROPERTY
0523-80
SIGNATURE
OF PERMITTEE
DISTRICT NO p ESSED BY
u U it
INDUSTRIAL
WASTE APPROVAL
WORKERS'COMPENSATION DECLARATION raAaarA /�
I hereby affirm that I have a certificate of consent to self caatrla-.a) APPLICATION FOR PLUMBING PERMIT iIfl
insure or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec 3800,Lob C)
COUNTY OF LOS ANGE LESBUILDING AND SAF TY
Policy No Company
El Certified copy n hereby furnished FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
❑ ADDRESS
Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM • FEE
departmentWATER CLOSET LOCALITY—;7—,J—_h
Date Applicant NEAREST
BATH TUB CROSS ST
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE SHOWER OWNER
LAVATORY MAIL \
(Thn section need not be completed if the work amohred ADDRESS ✓
by the permit as roar one hundred dollars ($100) or less) SINK CITY TEL NO-Zp'/'7
7
1 certify that in the performance of the work for which this DISHWASHER CONTRACTOR
permit as issued, I shall not employ any person In any manner v pip ¢
to as to become subject to the Workers' Compensation Laws CLOTHES WASHER ADDRESS0
Date Applicant SWIMMING POOL RECEPTOR U
NOTICE TO APPLICANT If, after making this Certificate of CITY TEL NO a
Exemption, you should become subject to the Workers LAWN SPRINKLER SYSTEM STATE LIC &
Compensation provtslons of the Labor Code, you must forth WATER HEATER LICENSE NO CLASS z
mi
with comply with such provisions or this pert shall be
deemed revoked GAS SYSTEM OUTLETS DISTRICT NO SED B
LICENSED CONTRACTORS DECLARATION OUTLETS OVER
1 hereby affirm that 1 am licensed under provisions of Chapter a PER SYSTEM
9 (commencing with Section 7000)of Division 3 of the Bust FINAL �7 VALIDATION
nets and Professions; Code and my license u m full force and
DATE 12 ' O/
effect
FINAL
License Number Lac Class BY
Contractor Date
I am exempt from the licensing requirements as I am a Plan Check foe
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEES `
acting In'my professional capacity (Seaton 7051 San
inns and Professions Code) TOTAL FEE
Lac or Reg No Date rName
check applicant
HOME OWNER BUILDER DECLARATION J
1 hereby affirm that I am exempt from the Contractor's ress
License Law for the following reawn (Section 7031 5 But, Tel No
nese ani of 111 Code) 221 4,3 A
R
owner of the property, am exclusavely contracting c
th licensed contractors to construct the project `
(Section 7044,Business and Professions Coda)
2 ° ° 2450
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency a ° 4 5 Q 5
for the performance of the work for which this permit is
issued(Sac 3097,Cav C)
12Q2-81
Lender's Name
' Lender's Address +
I certify that I have reed this application and state that the
above information u correct I agree to comply walla 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-mention ro rty for pection purposes -
Signature of Permittee Date 01