HomeMy Public PortalAbout9735 WOODRUFF AVE_Plumbing__ a
WORKERS'COMPENSATION DECLARATION 76A667A
I hereby affirm that I have a' certificate of consent to self ce 6171(z-6o) APPLICATION FOR PLUMBING PERMIT
insure,or a certificate of Workers'Compensation Insurance,or
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a certified copy thereof(Sec.3800,Lab.C.) 7
COUNTY OF LOS ANGELES / , BUILDING AND SAFETY
Policy No. Company'
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
❑' Certified copy is filed with the county building inspection
NUMBER FIXTURE OR ITEM FEE ADDRESS V
department. WATER CLOSET LOCALITY �f �• C/
Date Applicant NEAREST
BATH TUB CROSS ST. `;a 1! k
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE SHOWER OWNER kJff,if".Z I)OAI
LAVATORY MAIL �� da- �� ri
(This section need not be completed if the work involved ADDRESS
by the permit is for one hundred dollars ($100) or less.) }
SINK CITY /�doL� TEL.NO..`1&3�� 0
I certify that in the performance of the work for which this DISHWASHERV
permit is issued, I shall not employ any person in any manner CONTRACTOR
so as to becofne subject tothe WoorrkerM'Co ensation Laws. CLOTHES WASHER 0
� ADDRESS �O
Date '/ p
A licanG,-� - - SWIMMING POOL RECEPTOR U
NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL.NO. W
Exemption, you should. become subject to the Workers' LAWN SPRINKLER SYSTEM STATE LIC. N
Compensation provisions of the Labor Code, you must forth- LICENSE NO. CLASS Z
with comply with such provisions or this permit shall be WATER.HEATER
deemed revoked. GAS SYSTEM OUTLETS DISTRICT NO. PR CESSEP
LICENSED CONTRACTORS DECLARATION OUTLETS OVER 6 at
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000)of Division 3 of the Busi- FINAL VALIDATION
ness and Professions Code, and my license is in full force and DATE /S �
effect. FINAL
License Number Lic.Class BY '
Contractor Date
El I am exempt from the licensing requirements as I am a Plan check fee
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$
acting in my professional capacity (Section 7051., Bus-
iness and Professions Code). TOTAL FEE
Lic.or Reg.No. Date Plan check applicant
HOME OWNER-BUILDER DECLARATION Name U Q !G 1-tt12 2 J f 0 Al
I hereby affirm that I am exempt from the Contractor's Address C7 7 3 x- Qd .. gD a r i= 2fac.
License Law for the following reason (Section.7031.5, Busi- City T 14' 1,c 0/r Tel.No. 6`3vr7 Q
ness and Professions Code): 1 1 11,4A
I, as owner of,the property, am exclusively contracting
with licensed contractors to construct the project # o o o a o 5
(Section 7044,Business and Professions Code). L
2 0 o.1 600
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency 'O .!0-1 6000
for the performance of the work for which this permit is
issued(Sec.3097,Civ.C.). 0 9,1 4-81
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 SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above-mentioned roperty for inspection purposes.
F9-9 -091
'
Signature of ermittee Date
76A667-CE817 12/59
APPLICATION FOR PLUM! DNG PERMIT '
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER x
BUILDIIGAD S1�FETYIVISION ADDR SS
BM
BIE. OUNTY RMS
WILLIAM A.JENSEN,SUPT OP BUILDING
LOCALITY �--� •y��/�4
FOR APPLICANT TO FILL IN CROSSNEAREST .
NUMBER FIXTURE OR ITEM
OWNER
WATER CLOSET
GESSBTUB ADDRESS
ATH '" C
CITY TEL NO.
SHOWER
LAVATORY CONTRACTOR
ADDRESS
am
DISHWASHER CITY Zesr I& TEL. NO. AIV Z-Ai/.cP
CONTRACTOR'S STATE ❑
LAUNDRY TOB I REGISTRATION NO. 9r COUNTY ❑
CLOTHES WASHER 7WASTEAPPROVAL
. GROUP ZONE OCESSED BY.
WATER HEATER cp
GAS SYSTEIA
INSPECTION RECORD >.
w
V
r W
F
V
a
a
Q �
W $1.00 PER
Y
$ APPROVALS DATE INSPECTOR'S SIGNATURE
PERMIT S 2100 UNDER SLAB WORK
TOTAL FEE IV) ROUGH PLUMBING.
GAS PIPING ✓,1
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS PLICATION ' � y
AND STATE THAT THE ABOVE IS CORRECT AND AGR i0 COMPLY '.• GAS VENT All.
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING - HOT WATER- 11 `-Y�"
PLUMBING.
I HEREBY CERTIFY THAT I AM PROPERLY REGISTE AND/OR PLUMBING FIXTd..hiSP -�'
LICENSED AS REQUIRED S ANGE UN7Y STATE OF
CALIFORNIA OR THAI TH L ` WHER THE ABOVE GAS TEST If l.-
DESCRIBED RESIDENT! RUTILITY CO.NOTIFIEDLSIGNATIJ.
E 5r]PE
ERMiiTE !r y
! FINAL � I Vi� � �Y'�l�i•�f��_
DF VALIDATION ROBERT ,.'WOOD,
CK H.0. CASH SUPERVISING'MECHANICAL ENG'R
1r�L01525�;
FE 2 u 5 D :D.2 55 v
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