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\!1 APPLICATION FOR PLUMBING PERPAfT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIMION ESS
w'LD'N 6431 Temple City
JOHN A LAMBIE COUNTY ENGINEER
ESS
COLEMAN W JENKINS SUPT OF BUILDING Lock= Temple City
FOR APPLICANT TO FILL IN PR NT OR TYPE) CES
NUMBER FIXTURE OR ITEM EACH FEE
WATER CLOSET 1 50
77
WATER Dick Bowen
Khm BATH TUB 150 — DRFJSR 1600 Melanie Lane
/J SHOWER 1 50 (� CITY Arcadia TEL NO
�J LAVATORY 1 50 COxACr(@Wen Bron. Plumbing, Inc.
SINK I so ADDRERR 42 5 No. Baldwin Ave.
DISHWASHER I so p cITT El Monte 91731 TEL. No 443_0078
CLOTHES WASHER 150 U STAT! 1 741 LICC 36
LICENSE NO CLASS
SWIMMING POOL RECEPTOR 1 50 DI RIOT NO GRO 'ZONE
P BY
• p
LAWN SPRINKLER SYSTEM 2 00 . .
WATER HEATER 1 50 0 INDUSWASTE M➢60VAL Z
SYSTEM
GAS OUTLETS 150
/ �f .fes UMPECTIOW RECORD
OUTLETS OVER 30
5 PER SYSTEM
N
Z
I
Plan oheck let 2-,- of aboYe See reverse
PI UNIBING PERMIT ISSUING F LF S 2 00 '
I OTAL FFF
APPROVALS Are I TOR B H,TUR[
Plan check ippllrant UNDER SLAB WORK 7
Name ROUGH PLUMBING
Address GAS PIPING
CI[) lel No GAS VENT _
HOT WATER HEATER
I HERESY ACKMOWL[DO[ THAT I HAVE READ TNI[ wRLlcwilON
AN CTAT[ THAT TH[ AWv[ I[ colllaR wwD wale[[ To coMEtT PLUMBING FIXTURES �.
WITH ALL COUNTY ORDINANCt[ AND RAT[ LAW[ REGULATING GAS TEST 1 70
PLUMBING
I HEREBY CZWWY THAT R AM PNOP[NLT RI[GI[T[IED AND/ON UTILITY CO NOTIFIED
LICENSED A[ REQUIRED BY LO[ ANGELES COUNTY ANO RAT[ OF
CALIVM IA OR THAT 1 M THE "aAL OWIQR OF AMD 1 MD TO
RESIDE IM THE wSov[ SCRI Ili[NTML IIOP[ FINAL -70
SIGNATURE JACK R ALLEN, eUPERVISI HANICAL ENG R
OF PERMITT!
PERMIT VALIDATION CK M o CASH
PLAN CHECK VALIDATION CK M D CASH
4 5 4 49 APH17 5 D 2 0.00~
� I
I WORKER J have a certificate
DECLARATION to 7�DPW Bfae APPLICATION FOR PLUMBING PERMIT
I hereby-affirm that j have a cenlflcate of consent to esti Insure,
or a certificate of Worker a Compensation Insurance or a certified
copy thereof(Sec 3800 Lab C)
Policy No company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS DEPT OF PUBLIC WORKS DIV
❑ Candied copy Is hereby fummned
❑ cornfkw ivy Is Red with the FOR APPLICANT TO FILL IN PRINT OR TYPE) Ess 6431 Temple Cit Blvd.
pulls
department county NUMBER FIXTURE OR ITEM A FEE LOCALITY
Dale APplitam WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERSBATH TUB CROSS ST
COMPENSATION INSURANCE MAP KKR PARCEL
PAGE
(Thu eaetlon neW n
not be copNtthertmh
ed If iwork Iosd by the SHOWER
OWNER1.
I certify that in the performance of the work for which this permit
permit Is for one hundred dollars($100)or less) LAVATORY
is issued I shell not employ any person in any manner so as to MAIL
SINK became subject to the Workers Compensation Lewy ADDRESS G Y3 ' 7,- -,e, wIP,
DISWASHER CITY TEL NOV Y7-
air rya
Date Apparent CLOTHES WASHER CONTRACTORNOTICE TO APPLICANT If after making this Certificate of
Exemption you should became subject to me Workers Compensation SWIMMING POOL RECEPTOR
provisions of the Labor Code you must forthwith comply with such ADDRESS
provisions or this permit Mall be deemed revoked LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION CITY TEL NO }
I hereby affirm that I em licensed under provisions of Chapter B WATER HEATER
(commencing with Section 7000)of Division 3 of the Business and STATE UC
Professions Code and my license Is In full force and effect GAS SYSTEM OUTLETS LICENSE NO CLASS
OUTLETS OVER DISTRICT NP PROCESSED BY Ix
e PER SYSTEM
License Numbe Class . D o
DA n
Contractor Date _ VALIDATION
Z
Elrn 1 eexempt under Sec BY'"L At f T.Y v ?
B eP C for thle reason 307 '9.
Dela
Plan check fee T
►
PLUMBING PERMIT ISSUING FEE$ a 1 }' )'
SignaturePLUMBING
FEE To rz Z�0 - 30
Plan check applicant
SINGLE FAMILY
HOME OWNER BUILDER DECLARATION Name Seymour L. Mecum
I hereby affirm that I ern exempt from the Contractor a License Law
for the following reason (Section 7031 5 Business end Professions Address Temple City Blvd
Code)
I as owner of the Property will do the work antl the Temple Cit Tel No 818/447-9421e structure �c0
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 for the
performance of the work for which this permit le Issued(Sec 3087
Ctv C)
Lander a Name
Lander a Adtlreae
I certify that I have reed 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 above mentioned
pro for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
/= 8/moi
Signature of Permittee ' Date