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HomeMy Public PortalAbout6058 TEMPLE CITY BLVD_Plumbing__ 76A667-CE#817 4-64 APPLICATION FOR PLUMBING PERMIT COUNTY OF LOS ANGELES DEPARTMENT OF COUNTY ENGINEER BUILDING BUII"DING AND SAFETY DMSION JOHN A. LA E. COUNTY ENGINEER ADDRESS WILLIAM A.JENSEN,SUPT OF BUILDING LOCAL FOR APPLICANT TO FILL IN NEAREST " CROSS ST. NUMBER FIXTURE OR ITEM EACH FEE k / OWNER WATER'CLOSET 81:25 / BATH TUR 1.25 PA RES$ SHOWER 1.25J CI, TEL. NO. LAVATORY 1,85 a CONTRACTOR e I SINK 1,25 ADDRESS DISHWASHER 1.25 CITY TEL. NO. elderV LAUNDRY TUB 1.25 EGISTRATION NO. _j COUNTY ❑ CLOTHES WASHER 1.25 DISTRICT NO. GROUP ZONE OCESSED'BY WATER HEATER 1.50 Jr , p �^ 4 / �- GAS SYSTEM OUTLETS 1'� WASTE APPROVAL .8 OUTLETS OVER 5 PER SYSTEM .20 INSPECTION RECORD V �0�- f , IV d I Z I1 I APPROVALS D TB INSPECTOR-B SIGN/yT E PERMIT 55 2 00 UNDER SLAB WORK ROUGH PLUMBING I?P jllta A TOTAL FEE 5 GAS PIPING .". e,— r 1 HEREBY ACKNOWLEDGE THAT 1 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 140T WATER HEATER ' PLUMBING. ' 1 HEREBFY CERTIFY THAT 1 AM P OPERLY REGISTERED AND/OR LUMBING FIXTURES LICENSED AS REQUIRED BY LOS GELES COUNTY AND STATE OF GAS TEST CALIFORNIA OR THAT I AM T / GAL OWNER OF AND INTEND TO RESIDE IN,THE ABOVE DES KD ESIDENTIAL ROPERTY. ' TILITY CO.NOTIFIED SIGNATURE OF PERMITTEE INAL �'���o� -14/0 /VALIDATION ROBERT A.WOOD CK.,/ M.0.1 cnsH SUPERVISING MECHANICAL ENG'R Lri�o 6 4 54%"S' DEC 3 5 1 5,7 5" ? WORKERS'COMPENSATION DECLARATION ) APPLICATION FOR PLUMBING PERMIT I herebyaffirm that I have a certificate of consent to self 20-0026 DPW 6/87 in3lire; or a certificate of Workers'Compensation Insurance, 76A667A or d"certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS -Policy No. Company Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING /e �+I,Qr,c e t ,0 ❑ Certified copy is filed with the county building inspec- ADDRESS KJ L�-��"Izi rJwV tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY I WATER CLOSET 1A NEAREST n Date Applicant CROSS ST. 6A SS eA A UJ CERTIFICATE OF EXEMPTION FROM WORKERS' BATHTUB COMPENSATION INSURANCE OWNER (This section need not be completed if the work Involved by SHOWER the permit is for one hundred dollars $100 or less. MAIL 60572 AA/1 AI ,`/� P ( ) ) LAVATORY ADDRESS WWF IA4 I.certify that in the performance of the work for which this permit is issued,I shall•not employ any person in any manner SINK Q CITY `/►b TEL.NO. so as to become subject to the Workers'Compensation Laws. DISHWASHER r�_� CONTRACTOR AAAr42AL V®. Lc <, i DateApplicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificat of b47 i ©i'�tmgu Exemption, you should become subject to the Work rs' SWIMMING POOL RECEPTOR P Y I CITY (` TEL. NO. py Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM �p� � ° with comply with such provisions or this permit shall be STATE s-s a LIC. 2 deemed'revoked. WATER HEATER LICENSE NO. ���8-7 9 CLASS• V LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY I hereby affirm that l am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS �� d (commencing-with Section 7000)of Division 3 of the Business OUTLETS OVER G }} and Professions Code,and my license is in full force ciod effect. 5 PER SYSTEM FINAL VALIDATION iL License Number &N io'29 Lic. Class DATE 3�_GPI CC. ' ..���C FINAL (/ Contractor V_ k1014 mate Q BY k ❑ I arn exempt under Sec. Q LL B.BP.C. for this reason Plan check fee Date: • PLUMBING PERMIT ISSUING FEE$ (p Signature , TOTAL FEE �pO + Plan check applicant c SINGLE FAMILY v HOME OWNER-BUILDER DECLARATION Name f"A QJe_ ')d VS 1�1 TEMS I herebyaffirm that I am exempt from the Contractor's License ° ' /� Ya Law fothe following reason(Section 7031.5, Business and Address —7 CQ % CLvA 0 1W��E(L. �S•'.-...s 60 Low Professions Code): 1CIty Tel. No. ?P.CK }�; L+` ❑ I, as owner of the property, will do the work and the ,® C.HANGE ,; } structure is not intended or offered for sale (Section 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lendingagency for the pe4ormance of the work for which this perit is issued l 9"869-1 j j AM 911422 (Sec. 3097, Civ. C.). j Lenders Name r Lender's Address )) I certify that I -have read this application and state that the polo I 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-mentioned property f:gr inspection purp ses, SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date r}