HomeMy Public PortalAbout5300-5302-5304-5306 VILLAGE CIRCLE DR_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
ereby affirm tharl have 16 certificate of consent to self 76A667A
RIR insure, or a certificate of Workers'Comp satio Insurance, CE 817(REV 10/81)
I, or a certified copy thereof(Sec. 3800, L C.) COUNTY OF LOS ANGELES BUILDI AND SAFE
olicy No. Company r Ltt
❑ '
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspec- ADDRESS _,
ti department. NUMBER FIXTURE OR ITEM FEE LOCALITY
-
Date Appli4ant NEAREST WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER
(This section need not be completed If the work Involved by MAIL
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRES
I certify that in the performance of the work for which this
permit CONTRACT
is issued, I shall not employ any person in any manner SINK CITY T Ndw J
so as to become subject to the Workers'Compensation Laws. DISHWASHER 7
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR o
Exemption, you should become subject to the Workers' CITYTEL. NOVI
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM a '`
with comply with such provisions or this permit shall be STATE OF LIC.
deemed revoked. WATER HEATER LICENS 7 CLASS
LICENSED CONTRACTORS DECLARATION 6 'b VWR T NO. PROCESSED BY ti
S O
S
S SYSTEM OUTLETS �• s}1��
I hereby affirm that I am licensed under provisions of Chapter 9 GAC �:.tiiJ �� >_
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER 06
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL 'VALIDATION O
�- DATE ti
License Number Lic. Class ^t V
p.-� FIN L i � 0
Contract g Date--,* Ob ] �0 ` BY (�
❑ I am ex p er e .
( J
B.BP.C. for this reason Plan check fee
Signature
Date: PLUMBING PERMIT ISSUING FEE$ /
TOTAL FEE
SINGLE FAMILY
Plan check applicant
r
HOME OWNER-BUILDER DECLARATION Name J 1
I hereby affirm that I am exempt from the Contractor's License Address 1
Law for the following reason (Section 7031.5, Business and
Professions Code): City Tel. No.
❑ I, as owner of the property, will do the work and the I J
structure is not intended or offered for sale (Section ® V
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 is issued
(Sec. 3097, Civ. C.).
Lender's Name
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
above-me Toned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date
76A667(CE-617)- 5/73
APPLICATION FOR' PL ING PERMIT
COUNTY OF LOS ANGELES .z
DEPARTMENT OF COUNTY ENGINEER V
BUILDING AND SAFETY DIVISION BUILDING
MAKE CHECKS PAYABLE TO: ADDRESS 53 - 5306 Village Circle
HARVEY T. BRANDT, COUNTY ENGINEER LOCALITY Temple C7.fiy
FOR APPLICANT TO FILL IN (PRINT OR TYPE) NEAREST
CROSS ST. Baldwin Ave,
NUMBER FIXTURE OR ITEM @ FEE NoelBaldwin
'
WATER CLOSET y.7sf- �)0 OWNER
A
BATH TUB 1.75 J) DDRESS 5302 Baldwin Ave.
� O a
Y SHOWER 1 5 0 CITY emp @ 1 y TEL. N0.448-3907
LAVATORY 1 75 � t)o CONTRACTOR OWen Broo. plUMbj32gj Ino.
4 SINK 1 75 UV ADDRESS 4265 N. Baldwin Ave.
DISHWASHER 1 75 d ()� CITY El Monte TEL. N0.44�poq$
CLOTHES WASHER 1.75J01 6 STATE LIC
1 CLASS 036
_2Q
SWIMMING POOL RECEPTOR 1.75 LICENSE NO. 21
LAWN SPRINKLER SYSTEM 1.75 DIST NO. GROUP ZONE OCESS BY
STRLCSSD H
L[ WATER HEATER 1 75 ! �O INDUSTRIAL
WASTE APPROVAL
1. GAS SYSTEM 'OUTLETS 1 75 Uv INSPECTION RECORD V
OUTLETS OVER
5 PER SYSTEM ,30 O
U
W
a
C/7
Plan check fee See Reverse
PLUMBING PERMIT ISSUING FEE $
TOTAL FEE
APPROVALS DATE INSPECTOR'S SIGNATURE
Plan check applicant UNDER SLAB WORK /7-'75
Name ROUGH PLUMBING fir.
Address GAS PIPING d t 11 b
City Tel. NO. GAS VENT v
HOT WATER HEATER
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THEABOVE IS CORRECT AND AGREE TO COMPLY PLUMBING FIXTURES �,
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING. GAS TEST r
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR UTILITY CO. NOTIFIED
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO
RESIDE IN THE ABOVED RI RESIDENTIAL ERTY.
FINAL
SIGNATU RE '
OF PERMITTEE
PERMIT VALIDATION CK. MASH
PLAN CHECK VALIDATION CK. M.O. CASH
6 9 9 E"'NOV 3.0 .5 D 160.501-98