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APPLICATION FOR .PLUMBING PERMIT 1
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUII.MG AND SAFETY DIVISION BUILDING
JOHN A.LAMBIE. County es
CASSATT D.GRI17m,Supt of SuUZg LOCALITY
FOR APPLICANT TO FILL IN CROSS O
caoss sT.
NUMBER FIXTURE OR ITEM
WATER CLOSET OWNER
HATS TUB ADDRESS
SHOWER CITY TEL NO.
LAVATORY CONTRACTOR ALC
nmum 11349 xe Miloam St
alsHwAs R CITY, -Arcadia TEL.No. Hi 6 7588
Co1aTR21AZIO s 79 COUNTY
LAIINDRY TUB ' REGISTBATtoN NO. 179122
CLOTEIES WASSER DISTRICT NO. GROUP ZONE P ESSED BY
WATER HEATER
GAS SYSTEM INDUSTRIAL
WASTE APPROVAL
INSPECTION RECORD
IV
APPROVALS
1.R° sl
DATE INSPECTOR'S SIGNATURE
UNDER SLAB WORK
PERMIT $ 2 00 ROUGH PLUMBING
TOTALFEE ., GAS PIPING
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION GAS VENT
AND STATE THAT THE ABOVE iS CORRECT AND AGREE TO COMPLY HOT WATER HEATER
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING. PLUMBING FIXTURES
I HEREBY CERTIFY THAT .I AM ROPERLY REGISTERED AND/OR OAS TEST
LICENSED AS REQUIRED BY NGELES COUNTY AND STATE OF
CALIFORNIA OR THAT I THE LEGAL ER OF THE ABOVE UTILITY CO.NOTIFIED
DESCRIBED RESIDENTI PROPERTY.
L=0FPERMIIl—
E
FINAL
ROBERT A.WOOD.
®p TI SUPERVISING MECHANICAL ENG'R
(qfAlo
'E.G.
CASH
LG O 8 7 9-0� AUG 7 5 A 3.0 0
APPLICATION FOR PLUMBING PERMIT 1
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGIIGM
BMWING AND SAFETY DIMONSAM
rIOHN A.LAMM County Ea er °
CASSATT D.GRV=,Sap t of LOCALITY
FOR APPLICANT TO FAL IN CB77
S G v s D
NUMBER FIXTURE OR ITEM r
OWNER y
WATER CLASSY MAIL
BATH TOB ADDRESS
CITY TEL NO.
SHOWER
LAVATORY CONTRACTOR = f noe 5
SING ADDRESS ,/3'
DISHWASHER CITY L/ D TESL.NO. (j' --333/7 A l
CONTRACTOR'S l p A
LAUNDRY TOB REGISTRATION NO. /d d -E COIINTY
CLOTHES WASHER DISTRICT NOS GROUP Z NEREADY FOR INSPECTION
WATER HEATER /
GAS SYSTEM
WASTE AP'P'ROVAL
INSPECTION RECORD
a-
APPROVALS
0 $1.00 PER ITEM I e. DATE INSPECTOR'S SIGNATURE
OR FI7CPORE UNDER SLAB WORK -
PERMIT A.00 ROUGH PLUMBING tj" r- 1_7 Gt d1 t J t
TOTAL FEE GAS PIPING
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION ; GAS VENT id
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY HOT WATER HEATER
WITH ALL COUNTY ORDINANCES AND STATE LAWNS REGULATING PLUMBING FIXTURES.
PLUMBING. ✓
I HEREBY CERTIFY THAT I AM, PROPERLY REGISTERED AND/OR GAS TEST
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF f y
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE UTILITY CO.NOTIFIED
DESCRIBED RESIDENTIAL PROPERTY. _
SIGNATURE FINAL
OF .—Vol
PERMITTE _
ORERT A.WOOD.
Of ALIDATIO SUPERVISING MECPIANICAL ENG'R
CK. A
tR.O. CASpyR h �"
1�,0 7 5J CJ 5� tJU-*J 5 rJ 9.0 N}
"WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby,affirm that I have O certificate of consent to self 76AS67A
insure, or a certificate of Workers'Compensation Insuranee, CE 817(REV.8/86)
or a certified_c thr o (Sec. 38 L C.)
�� COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
P ompony
WU*
Certified copy is hereby furnished.
® FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDINGAftn+-t. '
Certified copy is filed with the county building in ec- ADDRESS
tion department. NUMBER FIXTURE OR ITEM @ FEE. LOCALITY
Date CF a Appligant WATER CLOSET NEAREST ,
CERTIFICATE OF EXEMPTION F M WORKERS' BATH TUB CROSS ST.
COMPENSATION IN
NCE SHOWER OWNER
(This section need not be completed If the work Involved by MAIL pp
the permit,is for one hundred dollars($100)or less.) 'LAVATORY ADDRESS-, `+
'I certify that in the performance of the work for which this e
permit is issued,I shall not employ.any person.in any manner .SINK CITY TEL..NO
SAX
so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTORflita
s
Date ApplicantCLOTHES WASHER. ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR p '
Exemption, you should become subject to the Workers' CITY V [/� TEL..N
Compensation provisions of the Labor Code, you must forth- {
LAWN SPRINKLER SYSTEM r '
With comply with such provisions or this permit shall be: STATE LIC. %w-
r n
deemed revoked. WATER HEATER LICENSE NO. CLASS ✓ l[/
LICENSED CONTRACTORS DECLARATION DISTRICTN0. PROCESSED BY
I hereby affirm that i am licensed Under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professioris Code,and my license is in full force
ra-nd ffect. ' 5 PER SYSTEM F6 OF INAL r KALI TIOI�E
License Number TE
L.ic. Class �/
� FINA �
Contractor Date iBY I�
I amex pt.under Sec. 8 01,•3 A �
B.BP.C.for,this reason Plan Check fee # 0 0 0 0 "0 5•
' Date: C `
PLUMBING PERMIT ISSUING'FEE$. S `t -6 1 6,50
Signature"
TOTAL FEE I 0 o o 1 &.5.0 5
SINGLE FAMILY
Plan check applicant .0.9.2 9_8 7 ¢
•
HOME OWNER-BUILDER DECLARATION } Name
I hereby affirm that I am exempt from the Contractor's License .' Address "
LOW for.the following reason (Section 7031:5, Business and
Professions Code):' City Tel.,No. I
1, as owner of the property,.-will do the work and the i
structure is not Intended or offered for sale (Section
1 7044, Business and'Professions Code).
CONSTRUCTION.LENDING AGENCY lk'
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued I
(Sec. 3097, Civ. C.).
Lender's Name
'Lender's Address.-
'I certify that I haveread this application and state that the
above inforrimation.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 1
above-mentio ed property for inspection purposes. ,
SEE REVERSE FOR EXPLANATORY LANGUAGE
157 '
r r ww , s
Stgnatu" of Permittee Date '
,