HomeMy Public PortalAbout5338 WELLAND AVE_Plumbing__ 76A667-CE817-8-57 Ei'71Y tI LJ LYJ li't r,
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APPLICATION FOR PLUMBING PERMIT. 1
QOUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER BUILDING
BUILDING. AND SAFETY DIVISION ADDRESS 3 L L /v
JOHN A. LAMBIE. COUNTY ENGINEER
CASSATT D. GRIFFIN, SUPT OF Bu1LDING LOCALITY 1
FOR APPLICANT TO FILL IN CROSSST
CROSS.ST.
NUMBER FIXTURE OR ITEM
OWNER AIS r C a
WATER CLOSET
BATH TUB ADDRESS L
SHOWER CITY 1, C .NO.
LAVATORY CONTRACTOR VilleY Plum in
SINK ADDRESS. 442 W. Fleetwoo
DISHWASHER CITY Gael dura, TEL.NO. lRd S—] 3
LAUNDRY TUB CONTRACTOR'SCOUN
a�® Pr COUNTY Ty NO. 9�$
TE
CLOTHES WASHER DISTR19X NO— GRQuP ON; I READY FOR INSPECTION
WATER HEATER —
GAS SYSTEM INDUSTRIAL
WASTE APPROVAL
INSPECTION RECORD
rf
r t; rrA ! sJ
Ar—
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APPROVALS
$1.00 PER ITEM DATE INSPE TOR'S SIGNATURE
OR FIXTURE $ UND SLAB WORK71
/
ROUGH PLUMBING
PERMIT S 1 00 e- I/- i
GAS PIPING
TOTAL FEE GAS VENT
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS A61 HOT WATER HEATER
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS .REGULATING PLUMBING FIXTURES
PLUMBING. / I
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR GAS TEST ,�-�f '4 1,
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT AM THE LEGAL OWNER OF THE ABOVE UTILITY CO. NOTIFIED
DESCRIBED RESIDENT PR ERTY.
4
SIGNATURE OF PERM TT INAL .��..;T•�ry" '%l,% � _
.0s IDATION ROBERT A. WOOD.
SUPERVISING MECHANICAL ENG'R
'CK. M.0. CASH
L_tv,02'5 0 6150 Jm 2 5 A 1. 1.00
I I
WORKERS'COMPENSATION DECLARATION I . AA w, ®ERM
I hereby, affirm that I have a certificate of consent to self in- 120-0076A66 PW 4/90 APPLICATION FOR �'WMBIN ® E,`MIT
sure,or a certificate of Workers'Compensation Insurance,ora
certified copy thereof(Sec. 3800, Lab. C.)
Policy No. Company I COUNTY OF LOS ANGELES EP . OF PUBL ORKS
Certified copy is hereby furnished. BUILDING
FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS
Certified copy is filed with the county building inspection
department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Date Applicant WATER CLOSET(TOILET) NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' I 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($100)or less.) LAVATORY ADDRESS
I certify that in the performance of the work for which this per- SINK CITY TEL.NO.
mit is issued, I shall not employ any person in any manner so
as to become subject to the Work om ensation Laws. DISHWASHER
�
/ CONTRACTOR
Date" jAppllc • CLOTHES WASHER ��®
NOTICE TO APPLICANT: If, after making this Certificate of Ex- ADDRESS
ou subject ',
em tionshould become suect to the WorkersCom en- SWIMMING POOL RECEPTOR
P Y I P CITY TEL.NO52Fe_y
sation provisions of the LaL-)r Code,you must forthwith comp- LAWN SPRINKLER SYSTEMS
ly with such provisions or this permit shall be deemed revok- STATE d �® LIC.
ed. WATER HEATER /.�' LICENSE NO. (� CLASS
QJ-
LICENSED CONTRACTORS DECLARATION •-J DISTRICT NO. PROCESSEb BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS �D p
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER CJ
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALID TION
fect. HOSE BIB DATE _
License Number fs✓® Lic. Clas IC �� }
FINAL + `�
Contractor 4"41 . Date BY
FJ I am exempt under Sec. I l-(( +- �. a2
B.&P.C. for this reason } s l SI-CL
Plan check fee r-. .;� ci
_v ..
Date: PLUMBING PERMIT ISSUING FEE$ f�
Signature
TOTAL FEE
SINGLE FAMILY , c 1_lJI_lJ—L1U('i 12/ 2'31'4
HOME OWNER-BUILDER DECLARATION Plan check applicant ;ti`0
I hereby affirm that I am exempt from the Contractor's License Name
Law for the following reason (Section 7031.5, Business and
Professions Code): Address
I, as owner of the property, will do the work and the City Tel. No.
structure 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 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-mentioned propert r inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date " /