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APPLICATION FOR PLUMBING PERMIT 1
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING,AND SAFETY DIVISION BUILDING
IOHN A. LAM M conn ��� ADDmms 543,6 idelland,
IF
CASSATT A GRU.Supt d Building LOCALITY Tem 1 C i t
FOR APPLICANT TO FILL IN NFJIRRST
CROSS or.
NUMBER FIXTURE OR ITEM
WATER GLOSSY OWN88
BATHTUB AD�RSSSD 4522 Huddart Street
SHOWER cm El Monte TEL'NO.
LAVATORY CONTRACTOR Fontana Plumbing Contr.
SINK ADDRESS 13329 E. Ector Street
DISHWASHER CITY Of Indust TELNo• ED 7-7226
TIIB CONTRACTOR'S STATE
LAUNDRYsEGIsTRATzoN iso. 96496 COUM ❑
1 CLOTHES WASHER DISTRI NO: GROUP Z NE SSED BY
WATER HEATER
]. GAS SYSTEM tA=
INSPECTION RECORD
APPROVALS
7 SI� ATE INSPEC;OR'S'SATURE
UNDER SLAB WORK
PERMIT $ 210
0ROUGH PLUMBING / q --
TOTAL FEE 9GAS PIPING
I HEREBY ACKNOWLEDGE THAT i HAVE READ THIS APPLICGAS VENT.
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COHOT WATER HEATER
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING. PLUMBING FIXTURES
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AGAS TEST �-
LICENSED AS REOU ED BY LOS ANGELES COU AND STACALIFORNIA OR I TH LEGAL 0 E UTILITY CO.NOTIFIED
DESCRIBED R L PE � ,.
SIGNATURE FINAL
OF PERMITTE
ROBERT A.WOOD.
®p VALIDATION SUPERVISING MECHANICAL ENG'R
CH. M.0. CASH
LEO 73499; JVJ 5 A 9.00
WORKERS'COMPENSATION DECLARATION APPLICATION FOR f�L1ep�®Ip,�rs PERMIT
I hereby, affirm.that I have a certificate of consent to self in- 20-0026 DPW 4/87 M /`� 9� E1� 4J" l�Bllill® 1��,7 n
5rke,or a certificate of Workers'Compensation Insurance,or a CE 817 A ,ul
P CE 817(REV.8/86)
certified copy thereof(Sec. 3800, Lab. C.)
Policy No. Company COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
❑ Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING r
❑ Certified copy is filed with the county building inspection ADDRESS G eq Al
department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Date Applicant WATER CLOSET(TOILET) NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. �EGL
S
COMPENSATION INSURANCE SHOWER OWNER Mod Kv f lt"
(This section need not be completed if the work involved by MAIL �/
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS j � N;// /t'
I certify that in the performance of the work for which this per- SINK CITY rr TEL. NO.�f �,/� t
mit is issued, I shall not employ any person in any manner so G� L� � d13''I6 a'
as to become subject to the Workers'Co ensation L s. DISHWASHER
I.y CONTRACTOR
XDate-l- • "Applicant CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate Ex- ADDRESS
em tion,you should become subject to the Workers'Com en- SWIMMING POOL RECEPTOR
P Y I P CITY TEL. NO.
sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok- I STATE LIC:
ed. WATER HEATER' LICENSE NO. CLASS
LICENSED.-CONTRACTORS DECLARATION DISTRICY_bLO. / PROCESSED BY
1 hereby affirm.that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS cD V/f
9,(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FDIAN EL VALID ION d
fect.
License Number Lic. Class O
V
FI
Contractor Date I O
I am exempt under Sec. W
V
CL
B.BP.C. for this reason Plan Check fee ® ;20857A W
Date: PLUMBING PERMIT ISSUING FEE$ J # 000-005
Signature
TOTAL FEE 1 - - 4(150
SINGLE FAMILY 0 0 0 4 0 5 Q
U
88
HOME OWNER-BUILDER DECLARATION Plan check applicant I Q 0 b"$
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 r
Lender's Address �G ,e
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- ntioned pr pert for inspection purposes.
Ni —Sg SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittey Date