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APPLICATION FOR PLUMBING PERMIT
COUNTY OF LOS ANGELES
+ DEPARTMENT OF COUNTY ENGIIQEE[i
BUII DINCT�ANg jiAFETY DMSION BUMDING %�6 S�1
JOHN A M I CouNTY ENGINEER ADDRESS -'
WILLIAM A JENBEN, SUP T OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN �TT,�
NUMBER FUTTURE OR ITEM OWNER
WATER CLOSET . d U MAN.
ADDRESS
HATH TDB i
S CRY TEL NO
SHOWER
_ CONTRACTOR
LAVATORY S O
SINKADDEMS�
S t
DDiHWASHER CRY, TEL N 6J
NIRA H
LAUNDRY TOB REGISTRATION NO E5 COUNTY
N®
CLOTHES WARA I? DIGTRICT NO I GROUP ZONE PR ED BY
WATER HEATERI ij,(J ° `-IL
O
GAS RYBTEM S p INDUSTRIAL \ / U
WASTE APPROVAL
INSPECTION RECORD 9
N
(ytG11'I _ Z
.f/ eg >r
If I/
-
I i/
• $ICU PER REM v ` r
OH FD[TUBE S / o APPROVALS r, DATE,
INSPECTOR/SIGNATURE
PERMITS 2 00 UNDER SLAB WORK 7 MK /"Si1�
TOTAL FEEROUGH PLUMBING
X GAS PIPING
IH
ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE 19 CORRECT AND AGREE TO COMPLY GAS VENT
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBINQ IHOT WATER HEATER
I HERESY CERTIFY T AT 1 AM PROPERLY REGISTERED AND/OR PLUMBING FIXTURES
LICENSED A9 REpUI B OB AMGELES COUNTY AND STATE OF GAS TEST
CALIFORNIA OS THA I THE LEGAL OWNER OF THE ASOV6
DESCRIBED RCBmENTI P UTILITY CO NOTIFIED
SIGNATURE
OF PERMITTE FINAL
0 ALIDATION ROBERT A WOOD
[X M o GASH SUPERVISING MECHANICAL ENO R
LAD 999-9� JAN 22 5 0 13,75- IP
M
75A908-(9E48I7 10-62
APPLICATION FOR PLUMBI G PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING S 3 S
JOHN A LAMBIE COUNTY ENGINEER ADDRESS
GWILLIAM A JENSEN SUP T OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN NEARSCROSS 57
NUMBER FIXTURE OR ITEM EACH FEE
OWNER r
Z WATER CLOSET 5175 121,110
MAIC
' BATH TUB 175 ADDRESS
SHOWER 175 CITY TEL NO
2 LAVATORY 125 {� CONTRACTORPITIRthing
/ SINK 125 / P ADDRESS 1Cren
DISHWASHER 115 CITY Hawthorne TEL NO OS 93691
LAUNDRY TUB 115 CONTRACTOR 193617 C-36 STATE
REGISTRATION NO couNTY B
CLOTHES WASHER 125 DI�B.TiRICT N G P Z NE P O ESS BY
WATER HEATER 1 50 ,'J 0 ,]I O lh/
GAS SYSTEM GUTLESS 1 ldd WASTEINDUS�/�PHOVAL O
OII7LLT5 OVEA 5 PER SYSTEM 70 INSPECTION RECORD U
O
r
yWy
Z
• J
- I
APPROVALS TE INSPECTOR S�S1�`6/i�ATUNE
PERMIT $ 2 00 UNDER SLAB WORK �Y ` / J,✓
"ROUGH PLUMBING 1 v
TOTAL FEE mGA5 PIPING I /
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION GAS VENT
ANO STATE THAT THE ABOVE 19 CORRECT AND AGREE TO COMPLY
WIIUTH ALL MBINO COUNTY ORDINANCES AND STATE LAWS REGULATING HOT WATER HEATER
1 HERESY CERT.FY THAT 1 AM PROPERLY REGISTENEO ANO/OR PLUMBING FIXTURES
LICENSED AS REQUIRED BY LOS ANGELES COUNTY ANDSTATE OF GAS TEST
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO
RESIDE .N THE ABOVE DE9cRIBe RE IDEHTIAL PROPERTY UTILITY CO NOTIFIED
SIGNATURE
OF PERMITTEE
FINAL
VALIDATION ROBERT A WOOD'
c M O CASH SUPERVISING MECHANICAL ENG R
Up
LAW 3 0 9 3 APP, 9 5 D 1 3 7 j
WORKERS COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT,,
`
z; lmiurebora irmcertificate
that I hover certificate of consent ra self 720 00266AS67 DPW 8/87 � a1 ,
mwre or a certifimte of Workers Compensation Insurance 78ABf17A `�t�'`•,��}G[ ep T�EEL�],@ C SIV 4S, r
or a certified copy thereof (Sec 3800 Lob C ) Y COUIV FY OFLOS AE LE:S'" DEPT OF PUBLIC WORKS'� ,
P❑ohq Nompon
iunwider -, y'
Cera led copy a ere y furnishMo' VEI �- s
1--I I - FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING `
Certified copy is filed with the county budding inspec ADDRESS
77C�" hon department NUMBER FIXTURE OR ITEM ® FEE
LOCALITY .
Date�ttlJe�AppltSon - WATER CLOSET'di. NEAREST �Ta '
r `•CeEERTIIFIICAATEE OOF EXEMPTION FROM WORKERS BATH TUB (; s att C STL., q%dillaq De
t COMPENSATION INSURANCE
(This section need not be completed R the wv
work Involved by SHOWER OWNER `r;^�#
the permn
it Is for one hundredle
dollan({100)or ss) LAVATORY - MAIL t
I certify that in the performance of the work for which this -
permit is issued I shall not employ any person in-any manner SINK _ CITY L tJ0
so as to become subject to the Workers Compensation Laws DISHWASHER
CONTRACT j
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT If after making this Certificate of SWIMMING POOL RECEPTORMe jl�eet Exemption, you should become subject to the Workers "
.
Compensation provisions of the Labor Code you must forth- , CITY
LAWN SPRINKLER SYSTEM A Anaeles
Tfl3-2Q
with comply with such provisions or this permit shall be STATE _LIC
deemed revoked WATER HEATER oo LICENSE NO CLASS
LICENSED CONTRACTORS DECLARATION v DISTRlCT14U +. PROCE D Y
I hereby affirm that I am licensed under prov ss cions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000)of Division 3 of the BusineOUTIETSOVER t Q
and Prof stato8
ns Code and my license is in full force and effect 5 PER SYSTEM t FINAL VALIDATION
License Number tol.--Lic Class_ DATE lA
FINAL J
ContractDate�y/p� BY
I am exempt under Sec
B 8P C for this reason plan check fee
Dote
PLUMBING PERMIT ISSUING FEES
•Signature d -
.TOTAL FEE AU
v i
SINGLE FAMILY
Plan check applicant - f.
HOME OWNER BUILDER DECLARATION Name -
I hereby offirm that I am exempt from the Contractors License ACt f 3
Law for the following reason (Section 7031 5, Business and Address C_1;7
Prof_iauons Code) City ] Tel No _ �aq�y , iC••r
1 ❑ I, an owner of the property will do the work and the
structure is not Intended or offered for Bale (Sedlon r, '
70", Business and Professions Code) , r - .mfr (�f�iti. :L ,. -.!C
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 f, 1' h,
(Sec 3097, Civ C )
Le
rider's�Nome
_
Lender s Address , ' _ - f` � .flJ^ ' ,� pm1'T5
rj
1 certify that I have read this application and itate that the
above information is correct I agree to comply with all County
ordinances and State laws regulating Plumbing and hereby '
authorize reprelentatrves of this County to enter upon the `
above mentioned propwtVT r inspection purposes i
9 SEE REVERSE FOR EXPLANATORY LANGUAGE � • - . . '}
'•- ,
Gi§6ur eritinrtt Date