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APPLICATION FOR PLUMBING PER/MIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
MAKE CHECKS PAYABLE TO I ADDRESS 5271 Sereno Ore
HARVEY T BRANDT, COUNTY ENGINEER LOCALITY
FOR APPLICANT TO FILL IN (PRINT OR TYPE) NEAREST
CROSS ST
NUMBER FIXTURE OR ITEM ® FEE
WATER CLOSET OWNER Phil ROCkenback
BATH TUB f 1 5 O ADDRESS 1012MAIL 8 Rash-Street
SHOWER i 5 CITU El Monte11 STEL NO 44,-5/
89
C% LAVATORY 1 5 O CONTRACTOR Br060pjnMbjng, IIID•
SINK 1 75 qn 0o ADDRESS 4265 N. Baldwin Ave.
9f9M'IFASFIER 75 JC)oCITY LFa DSOnte TEL N044 8
CLOTHES WASHER U 1 75 ` STATE - LIC
SWIMMING POOL RECEPTOR 1 75 LICENSE NO _ CLASS
DISTRICT NO _GROUP ZONE1 BY
LAWN SPRINKLER SYSTEM 1 75 �LL
WATER HEATER 1 75 V WASTETXPA
GAS SYSTEM OUTLETS 75 - ON RECO U
OUTLETS OVER
5 PER SYSTEM 9O CD
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Plan Check fee See Reverie �
PLUMBING PERMIT ISSUING FEE $
TOTAL FEE
APPROVALS DATE NSPEGS SIGNATURE
Plan check applicant I UNDER SLAB WORK
Narne ROUGH PLUMBING
Address GAS PIPING
City Tel NO GAS VENT
HOT WATER HEATER
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY PLUMBING FIXTURES
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUM NO GAS TEST
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR UTILITY CO NOTIFIED
LI LENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF I
CALIFORNIA OR THAT I AM THE LEGAL OWNER Or AND INTEND TO I
RESIDE IN THE ABOVE C ED RESIDENTIAL THE FINAL
SIONATU RE 1
OF PERMITTEE
PERMIT LIDATION cK M G CASH
PLAN CHECK VALIDATION CK M O CASH
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APPLICATION FOR PLUMBING PERMIT
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN(PRINT OR TYPE BUILDING5230 Rosemead
NUMBER FIXTURE OR ITEM • FEE ADDRESS
LOCALITY Temple City
WATER CLOSET O NEAREST
BATHTUB CROSSST
SHOWER OWNER George Fisher
LAVATORY MAIL
ADDRESS
SINK CITY TEL NO
DISHWASHER JA<
ACTOR JO e
ph Cadilli Plumbing Co.
CLOTHES WASHER SS 7821 East Garvey Ave
SWIMMING POOL RECEPTOR
Rosemead T W 01
LAWNSPRINKLER SYSTEM STATEWATERHEATER ENO 134935 ' LIQ C36
GAS SYSTEM OUTLETS APPROVALS DATE INSF 5KWATUAE
0�� 5 VER R SLAB WORK —I
j.-
"`" Y EM
ROUGH PLUMBING
Ica—
IGAS PIPING Q-
GAS VENT V
HOT WATER HEATER 0
PLUMBING FIXTURES
LASTEST
Plan check fee UTIUTYCO NOTIFIED _
PLUMBING PERMIT ISSUING FEE E
TOTAL FEE FINAL
Plan check applicant PLAN CHECK LYS" »L.CF-tel.
Name
Address
City Tel No 2 3 2 2 0 A
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATHIN MID STATE y G
5
THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WRH ALL COUNTY ORDINANCES # B • • • •
AND STATE LAWS REGULATING PLUMBING PERMIT VALIDATION n q
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR LICENSED AS —2200
L
REQUIRED BY LOS ANGELES COUNTY AND STATE OF CALIFORNIA OR THAT I AM THE
LEGAL OWNER OF AND I ENO TO RESIDE IN THE ABO SCRIBED RESIDENTIAL B 'f O O
PROPERTY G q
SIGNATURE • r0 3 14— ! 9
OF PERMITTEE
ze T
ISTRI NO BY L -
S O 8 I
INDUSTRIAL ,
WASTE APPROVAL
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c' L yl
i ��pORK€RS COMPENSATION a DECLARATIONent APPLICATION FOR PLUMBING PERMIT 3d
� . soaox DPW 4/87
• 'I'he�te5y, affirm that I have a cer�ihcate of consent to self In 76p607A
sure ora certificate of Workers Compensation Insurance ora CE 817(REV 8/80)
certified copy thErreaf (Sec 3800 La
COUNTY,OF LOS ANGELES DEPT' OF PUBLIC,WORKS
Policy No Company 4.,1 ObiblaL
❑ Certified copy is hereby furnished _
dr FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING �•�
adeepartme opy n filed with the county building rasp NUMBER FIXTURE OR ITEM @ FEE ADDRESS L
2_{� LOCALITY
Date _J `•o Applicant WATER CLOSET (TOILET) �b NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS
BATH TUB CROSS ST
COMPENSATION INSURANCE SHOWER O l) OWNER Na +
(This asidlon need not be completed H the work Involved by MAIL
the permit Is for one hundred dollars ($100)or Iess ) LAVATORY V ADDRESS
I certify that in the performance of the work for which this per I SINK d d CITY TEL NO
mit is issued, I shall not employ any person m any m niter so
a!to become subject to the Workers Compe DISHWASHER aCONTRACTOR
CORACTOR
Date.lL Applicant CLOTHES WASHER U U ADDRESS
NOTICE TO APPLICANT If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR
emption you should become subject to the Workers Compen
sotion provisions of the Labor Code you must forthwith comp- LAWN SPRINKLER SYSTEM CITY Clor,M .A TEL r- C/
ly with such provisions or this permit shall be deemed revok- STATE nl_ LIC
ed- WATER HEATER LICENSE NO LL.. ll CLASS —J
LICENSED CONTRACTORS DECLARATION W �J DISTRIa40 D y PROLE Y
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS S UA
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code and my license is in full force and ef- 5 PER SYSTEM FDIANAL _ VALIDAT d
fact �, `
License Number. - L,c Class r.-�� G
U
Q �a�j FI cc
Confracto Date 8 3 a B 1 O
F
I am exempt under Sec f.1
W
B 8P C for this reason a
Plan check fee , to
z
Date PLUMBING PERMIT ISSUING FEE S S
Signature TOTAL FEE 1 SO
SINGLE FAMILY
HOME OWNER BUILDER DECLARATION Plan check applicant ;10 3 4.3 A
I hereby off rim that I am exempt from the Contractors License Name # • e e e e 5
Law for the following reason (Section 7031 5 Business and
Profe=ons Code) Address 3 Q 5 0
I, as owner of the property will do the work and the Gty Tel No e •it 3 Q 5 0 6
structure is not intended or offered for sole(Section 7044 ,
Business and Professions Code)
� 0fl03�88
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 Ctv C )
Lender s Name
Lender's Address
I certify that I hove 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 representatives of this County to enter upon the i
above-mention pr rry rinspection Purposes
g _ 3_9 SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date