HomeMy Public PortalAbout5706 SULTANA AVE_Plumbing__ 7sAs67-csa17 s-so
APPLICA`C'ION FOR PLUMBING PERMIT �
DEPART OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION SIIILD NG � O
JOHN A. L.AMBIE. COUNTY ENGINEER ADDRESS Ems!
WILLIAM A.JENSEN.SUPT OF BUILDINa
LO
FOR APPLICANT TO FILL IN NEAREST
1. CROSS ST.
NUMBER FIXTURE OR ITEM OWNER
WATER CLOSET MAIL
SATE TUB ADDRESS
SHOWER
CPPV TEL.No.
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CONTRALTO
LAVATORY
sm ADDRESS
DISHWASHER CITY TEL NO. 4' G&
CONTRACTOR'S STATE
LAUMBY TUB REGISTRATION NO. LSI S COUNTY
CLOTFlES WASHER DISTRICT HO: 6 O P ZONE P ED BY
WATER NEATER J! OR
GAS'SYSTEM INDUSTRIAL y
WASTE APPROVAL
INSPECTION RECORD
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X11 �- t '' �v"i__�•«y
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Re �$ APPROVALS DATE. INSPECTOR'S S�IpQNATURE
PERMIT $ 2 00 UNDER SLAB WORK 2' "z'j ' .4"T"Azil f
TOTAL FEE ROUGH PLUMBING
GAS PIPING
I HEREBY ACKNOWLEDGE THAT I.HAVE READ THIS APPLICATION GAS VENT
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH. ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING. HOT WATER HEATER n
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR PLUMBING FIXTURES
LICENSED.AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF GAS TEST. ___
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTI PROPERTY. UTILITY CO.NOTIFIED
SIGNATURE
OF PERMInE
FINAL
�. VALIDATION ROBBRTk.WOOD,
R,O� CASR SUPEIiVI$NG MECHANICAL E:NG'R
I. Co2436% FEB 14 5 0 44.00
WORKERS'COMPENSATION DECLARATION APPLICATION FOR kUMBING PERMIT
I hereby affirm that I have a certificate of consent to self .I 20-0026 DPW 6/87
insure, or a certificate of Workers'Compensation Insurance, 76A667A
or a certified copy thereof(Sec. 3800, Lab. C.) � !q COUNTY OF LOS ANGELES I DEPT.OF PUBLIC WORKS
Policy❑ N .2ttc6mpany1-4401011-15S `G'Certified copy is hereby furnished:
I FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING `
Certified copy is filed with.the county building inspec- i ADDRESS
tion department. � NUMBER FIXTURE OR ITEM @ FEE LOCALITY /l•
Date A- A0
111 Applicant ` 46 WATER CLOSET NEAREST (i
• CERTIFICATE OF EXEMPTION FROM WORKERS'
BATHTUB CROSS ST. 4442�xl�
COMPENSATION INSURANCE -OWNER.
(This section need not be completed If the work Involved,by MAIL
SHOWER ,w,/''
the permit Is for one hundred dollars($100)or less.) 1 LAVATORY ADDRESS e,96099 /I/,Q&1 f�l�'ItrB!!J
I.certify that in the performance.of-the work for which"this I a� j/ ,
permit is issued,.I shall not employ any person in any manner SINK CITY Q TEL.NO.
so as to become subject to the Workers'Compensation Laws. DISHWASHER I ! fj/O
I CONTRACTOR
Date Applicant ii CLOTHES WASHER
ADDRESS
NOTICE TO APPLICANT:,If, after making this Certificate of
Exemption,=you should become subject to the Workers' SWIMMING POOL RECEPTOR I /
CITY TEL.NO�•� f✓
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM •
with comply with such provisions or this permit shall be '� STATE LIC. ?/
deemed revoked. WATER HEATER g7J LICENSE NO. I����_ O CLASS
LICENSED CONTRACTORS DECLARATION. i DISTRICT NO. PROCESSED BY'
I hereby off irm-that I am licensed under provisions,of Chapter 9 .1 GAS SYSTEM OUTLETS
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER•
and-Professions Code,and my license is infull force
/and
�effect. 5 PER SYSTEM ,PATE
Z� VALIDATION
License Number tl���a Lic.,Classes
FINAL
Contractor—&I AKWhWig Dote 3! BY p
❑ I IC=7c
I am exempt under Sec. I W
B. P. ..for this reason
�1CPlan.check fee �
Date. PLUMBING PERMIT ISSUING FEE$
Signature ^ j
TOTAL.FEE d•v
Plan check applicant
SINGLE FAMILY ,
HOME OWNER-BUILDER DECLARATION Name I i=�t.:( i ea
I hereby affirm that lam exempt:from the Contractor's License I 7;+;i^
Law for the following reason (Section 7031.5, Business and Address ,33=! �+}■ _::
Professions Code): City Tel. No. y ;- ' .
❑ I, as owner of the property, will do the work and the g' I TTIA IA 3 -30.
structure is not intended or offered for sale (Section l
L.
7044, Business and Professions Code). pop CHECK
CONSTRUCTION LENDING AGENCY i (� �' ns
I hereby affirm that there is a constryction lending agency-for ANNE
the performance of the work for which this permit is issued
(Sec, 3097,Civ. C.). I J1 31
Lender's Name II 1543 1. PM1 a �;
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 representatives of this County to enter upon the I +
abo tion .'property for Inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date
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