HomeMy Public PortalAbout9110 WOOLLEY ST_Plumbing__ VWYKERS'GOMPfjVSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
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sy 1qf?irm tbWW l have p certificate of consent to self 76A667A 1�
-Insoi•V'6r 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
olicy No.-Company
❑ Certified copy is hereby furnished. BUILDING `a ,
F-1ADDRESSAPPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS
Certified copy is filed with the county building inspec-
tion department. NUMBER FIXTURE OR ITEM @ FEE
LOCALITY
Date Applicant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE �y OWNER
(This section need not be comploted if tho work Involved by SHOWER V
tho ermit is for one hundrod dollars $100 or less. f' MAIL Q '�
P ( ) ) � LAVATORY eV ADDRESS
I certify that in the performance of the work for which this
permit is issued, I shall not emplo ny person in any manner SINK CIT TEL. NO,;kJ
so as to become subject to the W�rkA�Co nsation Laws. DISHWASHER t� !!!6 cr
�9 CONTRACTOR
Date Applicant CLOTHES WASHER 00 ADDRESS
NOTICE TO APPLICANT: If, after Naking this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers' CITY TEL.NO.
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER /y LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION v DISTRI�O.` O ED Y
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL _ VALI TION
DATE >
License Number Ltc. Class C
FINA L
Contractor Date BY a
❑ I am exempt under Sec. C
B.$P.C. for this reason
Plan check fee a
Date: �4 61,2 A
Signature PLUMBING PERMIT ISSUING FEE$ a 2
TOTAL FEE # 0 0 0 0 0 5
SINGLE FAMILY Plan check applicant I a o64,50
HOME OWNER-BUILDER DECLARATION Name iARA& - 64.500
I hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business and o 0509"86
Prof ions Code): Cit Tel. No
I, as owner of the property, will do the work and the JL
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
VN
ntio d property for inspection purposes.
�+ SEE REVERSE FOR EXPLANATORY LANGUAGE
l /�LBc
Sig ature of Permittee Date
D.B.S.-Ir 25M SETS 6-46 APPLICATION FOR PERM
DEPARTMENT OF BUILDING AND SAFETY
COUNTY OF LOS ANGELES. PLUMBING
WM.J. FOX.CHIEF ENGINEER �"
NATURE OF INSTALLATION DISTRICT o: GROUP I ZONE. P RMIT No
RQUGH •FIXTURESCOMPLETB �-
HEATER 'CESSPOOL HSEPTIGTANK RE EIVED�Y READY FOR DA ISSUED
FIRST INSPECTION � �� '
AS• MISCELLANEOUS
APPLICANT FILL IN HEAVILY'OUTLINED PORTION ONLY
JOB
E HAM. C. NOTTINGHAM CO. ADDRESS/7.7
OF TEMPLE CITY' -
ADDRESS _ LOCALITY123
D • NEAREST
d CITY TEMP�E��TvE +r '� cRoes Sr.- w�✓ b1/�ra
coUNTY
CERT.No. EXPIRES NAME
LOCATION OF SEPTIC TANK, OR CESSPOOL M
E AIL
_ 3 ADDRESS
NORTH , O "
CITY TEL.NO.
I AM THE LEGAL POSSESSOR OF .THE ABOVE LOS
ANGELES COUNTY CERTIFICATE OF QUALIFICATION.
y� V NEER
I AM THE LEGAL OWNER OR THE PROPERTY'DESCRIBED.
ABOVE.
3 OWNER
CORRECTIONS
SOUTH
DESCRIPTION OF WORK z
BATH TUB FURNACE
E
SHOWER DISHWASHER 13
LAVATORY REFRIGERATOR
KITCHEN SINK WATER SOFTENER
FLOOR SINK SAND TRAP
LOP SINK FLOOR DRAIN
WASH TRAY URINAL APPROVALS
WATER CLOSET DRINKING'FOUNTAIN• DATE' INSPecroR'sNANE
WATER HEATER DENTAL LAVATORY ROUGH PLUMBING I
METER GAS aODA FOUNTAIN
CUTL. GAS PIPING I I
.GAS VENT I. I
CESSPOOL I
/ TOTAL NUMBER OF FIXTURES SEPTIC TANK I I
` CESSPOo� SEPTIC TANK SEWER
S UTILITY CO.NOTIFIED I
TOTAL FEE FINAL Q� qi