HomeMy Public PortalAbout5032 SERENO DR_Plumbing__ a
DEPAA$TMENT OF BUILDING AND BArM 1 APPLICATION FOR PSRffiT 1
COUNTY OF LOB ANGELES PLUMBING
WY. J. FOX.CHIP WMINEER
NATURE OF INSTALLATIONr
.'
ROUEN FIXTURE@ COMPLETE ,==f
. READY FOR DATE ISSUED
HEATER CQDEPOOL SEPTIC TANK RECQIYED DY NOT N(q—011 _ ;2,5
..
APPLICANT FILL IN HEAVILY OUTLINED PORTION ONLY
Los
NAY[ ADDRESS
ADDRESS LOCALITY
NEAREST
CITY o. CROP ET
COUNTY C
CSRT NO OIPIRES NAYS
LOCATION OF C TANS, OR CESSPOOL MAIL
HORTH Td NO.
CITY
1 AM THS LEGAL POSQE1iOR AIIF�K AWOV0IC LOS
ANGELES COUNTY CERTI
N.
FLIT m
I AM THE LEGAL OWNER OF THE PROPERTY DESCRIED
ABOVE.
• OwI101
CORRECTIONS
SOUTH
a
DESCRIPTION OF WORK Z
F3
ATH TUB -PURNACE ¢
a
HOWER ^I[HWASHER
VATORr R"RIOOIA'TOR
TTCHEN SINK WATER SOFTE•IER
R SINK RIND TRAP
SINK FL0011 DRAIN
WAEN
TRAY URINAL APPROVALS
ATER CLOSET ^RINKINO FOUNTAIN DATE NIR6TOR A NAY■
WATN HEA DENTAL LAVATORY ROUGH PLUMBING J"
O^^A FOUNTAIN a"PIPING r �`
OUTL
SAE VOLT
CESSPOOL
TOTAL NUMBER OF FI TTURES m S SXPTIC TANK +
[SRPOO REPTIC TANK �EEWER
S-,t, UTILITY CO NOTIPIID - �,
TOTAL I
WORKERS'COMPENSATION DECLARATION 2D-W26 DPW 4/90 APPLICATION FOR PLUMBING PERMIT
I hereby, affirm that I have a certificate of consent to self m- 76A667A
sura,or a certificate of Workeri Compensohon Insurance ora yUl
certified copy thereof (Sec 3800, Lab C )
COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORM,1
Policy No Company '
Certified copy is hereby furnished
FOR APPLICANT TO FILL IN(PRIM OR TYPE) IfUItDI SSG
Certified copy a filed with the county building inspection ADDRES
department NUMBER FIXTURE OR REM ® FEE LOCALITY c r
WATER CLOSET(TOILET) C. G.
cjTy CA
Dote ApMPTIOant CRO55 ST 0
CERTIFICATE OF EXEMPTION FROM WORKERS �'TM TUB
COMPENSATION INSURANCE SHOWER OWNER
(This section need not be completed H the vir rk Involved by MAR
tM permit Is for one hundred dollen({100)or less ) LAVATORY ADDRESS
I certify that in the performance of the work for which this per app -Tr�`,�p/ -�p� '�ry
mit is issued I shall not employ any person in any manner so g SINK � I L/V IE c IR NO --o /-J--r2
as to become subject to the Workers Compensation Laws DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHER
ADDRESS
NOTICE TO APPLICANT If, after making this Certificate of Ex-
SWIMMING POOLRECEPTOR
emption,you should become subject to the Workeri Compen-
sobP LAWN SPRINKLER SYSTEMS
provisions of the Labo-Code you must forthwith comp- CITY TEL NO
ly with such provisions or this permit shall be deemed revok- STATE LIC
ed 1' WATER HEATER LICENSE NO CLASS
LICENSED CONTRACTORS DECLARATION Ol1TlET5 DISTRICT NO PROCESSED BY
I hereby affirm that I am licensed under provaG,45 SYSTEM
lons of Chapter
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
R
and Professions Code, and my license is in full force and of- 5 PSYSTEM FINAL ArAWATION
fect HOSE&B DATE
License Number ' L,c Class �) S.rQ� 1�i5.4`.' 0
V
FINAL
Contractor Date BY
F] I am exempt under Sec T13TPL 165 . 45
��t�f`
165.45
Date PLUMBING PERMIT ISSUING FEE$ a p ► CHM'a •CI'I
Signature
SINGLE FAMILY TOTAL FEE Bloc-nool 6/22/'y4
HOME OWNER BUILDER DECLARATION Plan check applicant
I hereby off um that I am exempt from the Contractor's License Name 177:
Law for the following reason (Section 7031 5 Business and `
Professions Code) Address
04 I as owner of the property will do the work and the City Tel No
l�
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 fa
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 repres tatrves of this County to enter upon the _
ave-mentione roperty for mspechon purposes
/� /ruT,_gig
SEE REVERSE FOR EXPLANATORY LANGUAGE
nature o Pe iaee Date