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Home My Public Portal About4928 WILLMONTE AVE_Plumbing__ WORKE) COATION DECLARATION Csnae7 APPLICATION 9® A y FOR PLUMBING PERMIT, Io7tereb I have affirm that have a' certificate of consentE to self 'ce17(z-ao) r P P L I C A T I O�tl insure,or a certificate of Workers'Compensation Insuranceror ' u :oIicy'No._T:ZZ6 certified co yreof(Sec.3800,Lab.C.) lp � g-Jru COUNTY OF LOS ANGELES / ' BUILDING.AND SAFETY om an) E] Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING01 J, /` 1 NUMBER FIXTURE OR ITEM FEE ADDRESS (/i/ 2 Certified copy is filed with th ty bui g' ecti departme t. alai WATER CLOSET LOCALITY Date� Applicant NEAREST BATH TUB CROSS ST. CERTIFICATE OF EXEPTION FROM WORKERS' COMPENSATION INSURANCE SHOWER OWNER M11K LAVATORY MAIL ' ALI (This section need not. be completed if the. work involved � ADDRESS _ } by the permit is for one hundred dollars ($100) or less.) SINK CITY TEL..NO. 0 I certify that in the performance of the work for which this DISHWASHER �9• ] V permit is issued, I shall not employ any person in any manner CONTRACTOR (� �r so as to become subject to the Workers'Compensation Laws. i CLOTHES WASHER 0 ADDRESS � ` � O Date Applicant SWIMMING POOL RECEPTOR CITY ` TEL.N d NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE LIC to Compensation provisions of the Labor Code', you must forth- LICENSE NO. SS Z with comply with such provisions or this permit shall be WATER HEATER deemed revoked. GAS SYSTEM OUTLETS DISTRICT NO. OCESSED BY LICENSED CONTRACTORS DECLARATION OUTLETS OVER I hereby affirm that I am licensed under provisions of Chapter 5.PER SYSTEM 9 (commencing with Section 7000)of Division 3 of the Busi- FINAL p VALIDATION ness and Professions Code,and my license is in full force and DATE effect. FINAL License Number• sld �'b ic.Class �C13 BY ' Contractor Date / F1 I am exempt from the licensing requirements as I am a Plan Check fee 'Y �� licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$ acting in my professional capacity (Section 7051,, Bus- iness and Professions Code). TOTAL FEE w Lic.or Reg.No. Date Plan check applicant HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's /address License Law for the following reason (Section.7031.5, Busi- City Tel.No. ness and Professions Code): O U 2 b A ElI, as owner of the property, am exclusively contracting with licensed contractors to construct the project fj o a c o o (Section 7044,Business and Professions Code). 2 -1 - 13.00 CONSTRUCTION LENDING AGENCY . 0 0 0 1 O O I hereby affirm that there is a construction lending agency v for the performance of the work for which this permit is 0721 -81 issued(Sec.3097,Civ.C.). Lender's Name Lender's Address ,I..certify that I haveread this application and state that the above information is correct.I agree to comply with all County SEE REVERSE FOR EXPLANATORY LANGUAGE ordinances and State laws regulating Plumbing, and hereby authorize repr tatives of this C to enter upon the above-me n property r ins ct' pur - 2 /-rl ignat o Permittee Date WORKERS'COMPENSATION DECLARATION APPLICAMN FOR PLUMBING PERMIT I herdGy affirm that I have a certificate of consent to self 76A667A insure, or a certificate of Workers'Compensation Insurance, CE 817(REV. 10/81) or a certified copy thereof(Sec..3800, Lab. C.) COUNTY OF LOS ANGELES / / BUILDING AND SAFETY Policy No. Company + Certified copy is hereby furnished. ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) 841LDING Certified copy is filed with the county building inspec ADDRESS 9 t� tion department. NUMBER FIXTURE OR ITEM Q FEE / / WATER CLOSET LOCALITY Date Applicant NEARST CROSS ST. �.; CERTIFICATE OF EXEMPTION FROM WORKERS' BATHTUB COMPENSATION INSURANCE SHOWER OWNER a fig, (This section need not be completed If the work Involved by MAIL the permit is for one hundred dollars($1100)or less.) LAVATORY ADDRESS I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK CITY TEL.NO. P 7 so as to become subject to the Workers'Compensation Laws. DISHWASHERi CONTRACTO Date 7 7$3 Applicant W ` • INL4inV -+ CLOTHES WASHER NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR ADDRESS 2 Exemption, you should become subject to the Workers' �• Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY TEL.NO. r22fo Q with comply with such provisions or this permit shall be STATEc�C LIC. �^ f deemed revoked. 'WATER HEATER LICENSE NO. : /p ZI CLASS 4, LICENSED CONTRACTORS DECLARATION DISTRICT NO. P SID,BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS (commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code,and my license is in full force and effect. 5 PER SYSTEM �� FINAL VALIDATION 0 r _ License Number�C1g� 4 Lic. Class �-.�G � eg , �, FINAL A� O �� Contractor C✓�� a Date Z.7•1?-4 ' BY V 66A I am exempt under Sec. B.BP.C. for this reas .•tl/t%.em Plan check fee PLUMBING PERMIT ISSUING FEE$ 3 4 6.0 A Signature TOTAL FEE 120 IS-0 +i a o o 0 o 5 Plan check applicant SINGLE FAMILY 2 o o 3 O.5 0 HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Address o u o 3 Q 5 0 mu Law for the following reason (Section 7031.5, Business and • Professions Code): City Tel. No. ir'0 7 8 3 ❑ I, as owner of the property, will do'the work and the 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 / c� the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). tender's Name , Lender'sAddress 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 I above-mentio a er r inspection purposes. + SEE REVERSE FOR EXPLANATORY LANGUAGE , e Signaturof P�j flee Date 78AGG7 (CE-817) -1./73 e. APPLICATION FOR UMB G PERMIT COUNTY OF LOS.ANGELES DEPARTMENT OF COUNTY ENGINEER. BUILDING AND SAFETY DIVISION MAKE CHECKS PAYABLE TO: BUILDING ADDRESS � HARVEY T. BRANDT, COUNTY ENGINEER LOCALITY FOR APPLICANT TO FILL IN (PRINT OR TYPE) NEAREST NUMBER FIXTURE OR ITEM ® FEE CROSS ST. WATER CLOSET 2.00 OWNER - MAIL BATH TUB 2.00 ADDRESS SHOWER 2.00 CITY TEL. NO. LAVATORY 2.00 CONTRACTOR SINK 2.00 .7�f ADDRESS DISHWASHER 2.00 C ITY NO. CLOTHES WASHER 2:00 STATE LIC SWIMMING POOL RECEPTOR 2.00 LICENSE NO. CLASS DISTRICT NO.JGROLIPJ NE P' CES D BY LAWN SPRINKLER SYSTEM 2.00 dd — �� I WATER HEATER 2.00 INDUSTRIAL �. WASTE APPROVAL a GAS SYSTEM OUTLETS 2.00U INSPECTION RECORD v OUTLETS OVER ` ,30 O 5 PER SYSTEM H• - V • W Ct Cn Plan check fee See Reverse PLUMBING PERMIT ISSUING FEE $ I L10 TOTAL'FEE APPROVALS DATE INSPECTOR'S SIGNATURE Plan check applicant UNDER SLAB WORK Name ROUGH PLUMBING Q ei Address GAS PIPING Iv-d City Tel. NO. GAS VENT HOT WATER HEATER .I HEREBY ACKNOWLEDGE THAT 1„HAVE READ THIS APPLICATION / AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY PLUMBING FIXTURES WITH ALL COUNTY ORDINANCES AND. STATE LAWS REGULATING ` PLUMBING. OAS TEST '��, •'� I HEREBY CERTIFY ,THAT I AAA PROPERLY REGISTERED AND/OR UTILITY CO. NOTIFIED LICENSED AS REQUIR LOS ANGELES COUNTY AND STATE OF CALIFORNIA OR TNA I AM E LEGAL OWNER OF, AND IFT@ND TO REST DE IN THE ABOV DESCRI D RESIDENTIA PROP RTY.-9 FINAL SIGNATURE O_F PERMITTEE • PERMIT VALIDATION (:C:K �); CASH PLAN CHECK VALIDATION CK. M.O. CASH 'p 6 3 .0 jAAI 12 5 U :L C).5O Az;O 7WQ7--=17-II-57 APPLICATION FOR PLUMBING PERMIT 1 COUNTY OF LOS ANGELES DEPARTMENT OF COUNTY ENGINEER BUILDING BUILDING AND SAFETY DIVISION ADDRESS „,? LvI L L TrOHN A.LAMBIE. CountT EO ''neer CASSATT D. GRIFFIN.SOP t of SuRdiug LOCALITY FOR APPLICANT TO FILL IN NUMBER, FIXTURE OR ITEM OWNER WATER CLOSET MAIL ADDRESS BATH TUB Yl,- f SHOWER CITY N LAVATORY CONTRACTOR valley numbing co. sm "DRESS 442 W. Fleetwood Pl. DISHWASHER CITY Glendora TEL.No. Ed 5-12 CONTRACTOR'S 160847SMA-TE ❑ LAUNDRY TUB REGISTRATION NO. COUNTY CLOTHES WASHER D18TRICT NO.7 + GROUP ZgNE EADY FOR INSPECTION WATER HEATER ••(�„�_"' /v�. �, GAS SYSTEM INDUSTRIAL WASTE APPROVAL INSPECTION RECORD APPROVALS f� 1' @ $1.00 PER ITEM rj ATE INSP=, OR=S•SI,GNATURE R FIXTURE ; UNDER S=%B'WORKta /lam — PERMIT' $ 00 ROUGH PLUMBING OW TOTAL FEE +� GAS PIPING GAS VENT I HEREBY ACKNOWLEDGE THAT I HAVE READ THi APPLiCA?tON 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 PROPERLY REGISTERED ANDAR GAS TEST LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF CALIFORNIA OR THAT I AN THE LEGAL OWNER OF THE ABOVE UTILITY CO.NbTIFIED DESCRIBED RESIDENTIALR PERTY. C SIGNATURE FINAL OF PERMITT R06ERTA.WOOD. ®F ATION SUPERVISING MECHANICAL ENG'R • Fr O. CASK a L&.2-2Z 41% f.B 4 5 A 12.0.0 A