- 2031 MARIPOSA AVE E (3) PLUMBING PERMIT
APPLICy�f T ((��� p -
c►Jt.9t►JE 1 LUNgtN City of El Segundo
ADDRESS BUILDING SAFETY DEPARTMENT
2vFr
r ZIPgO I'' PHONE pA I Building sty IMA 12�pCSA
Building NO
o N l �`/i� LLJ Blacrk/Page Lot/Parcel
NAME
W ^ 1 certify that I have read this application and Stale that the above Information Is correct.
2 ADDRESS PHONE -
3 �0 ee 1 agree to comply with all city and county ordinances and state]amtelatlnp ro building
CITY ` �,O STATE)ZIP O construction,and hereby authorize representatives of this city to enter upon me above
mentioned property for Inapectlon rposes.I� NAME
ADDRESS' �PVONE q -----,— ---
= Signature of AitolicitamiQ5 Agent D to
U
c Cff1' STATEIZIP
W NAME PC No v No of Plans Resld
W
2 ADDRESS PHONE
Data Commintltnt
W CITY STATE)ZIP � ^
NAME EN �� t� PC Ed L Quantity Fees
MAILING ADDF]FSS l Each PlumbingFixture
t W o0 2u"r rygA
c C1 I O SO h-�c f TE Z$N O O\O 1 Sewer
cSTATE C—A ZIP Cl CITY LIC NO O
x ere I hereby affirm under penalty of perjury dal I am w d licensed under promm, Chapter 9 Water DISpBnsing Equipment
V (mrrvnertottp with Sacemt 7000)of DNLslon 3 of the Business am Profess ins Come.am -
my lkense Ism to f anect 7 >54
1-flown.Class La, Na o8"1 Water Pressure Regulator
�_ L
Date Cont, signpmr. - potable Water System
WORKER'S COMPENSATION DECLARATION
I hereby within under penally of perjury one of me following declarations Gas $ stem
_I nave end will m ion a caMaab of mna i m ea tics ad,wafkari
x mmpansamn,as dovaed Id by Seclbn 37m of dro Mom
pedormaiK.w -
O al me work for whim Mae pamu o usum '1l V Water Heater
1 have am wM memrom wodars'mmpansamn i }{ om section
C 370D of Me Lobar Coact,Ica Ms rtormanp of ins work Id nick Mr. Water Heater Vent
y peperms w nsum
x My works om eneae neuron center and policy number p.D.�
Comer Policy Number 1I,US 4 '�!
�` (Tws saebwn need rid be eomplea n me permit is for one hundred dollars(S10D)or Its
Swimming Pool
C _I cenlh that in the padomance all me work for which Me Permit is Issued I shall not Spa
V Shot any Person In any manner so as to became abject to Me workers'mmposs—hon
q Laws of Cdibma,end agree coal 11 should become sublectro me workers'compensation
Wprowsrona of Sx1 on 370D of Ise Lab-Cade 1 shall Iprtlll m mmph M In° Solar Systems Collector
Provabn.
C Daa Slgnanae Solar Storage Tank
3 WARNING_F-tiro to seduce works'mmpamauon coverage Of unlawful,ands all
subject an employer to criminal penelaes am civil films up to one hundred mousam Back Flow Devito
dollars(5100,000),inmlm non to me mat of compensation,times"as provided for in
Sam on 370e of the Labor Code,interest dna adomey's fees
1 hereby amen under penalty d bleary mat I am euna l ham in,contractors License Law Lawn Sprinklers
for the foll/Shb
ing reason(Sac 7031 5 Business am Profeasans Cmaf Any ry or county
which reqs a Permit to wmaucl,din,improve,demolish o repair a sWcture,error
rolls issue,also requ me applicant for such permit ro eb a apn sister an her ha Vacuum Breakers
Of sine a licensed pursuant ro ma prorawro of me Comred-s Lice a Law IChep 9
(mmmen ins Semon]0p0)of ONision 3 Of Iha Buvness rotessrons Cme)d
Met ire or a eaempl therefrom and Vro bow Ica ma ado aneaempwoIn My vidawon
of Section31.5 by any applicant for a pants Sub jeda m applicant to a civil Penally of 2 [��
not more n fare hundred dollar;M500))) PERMIT FEE (Sub Total) :71 . Oy
Wr of the property-my empbyeed with ages u their sore daft;ao me woam me seucerro 1a not mmmao or ed for sale(Sec 7oa4 Business andREMARK$
Prolessiooda) The Conuoctors License L dins not apply to on owner feapropey Plan Check Fee improves morean,am who d s such woe himself or through nuor her OwnQampioyaerovided mat cam Improve is are not intended or offered for sale II Plan Rel Fee
however, building or improvemen sorb wham one year al completion,me owned-
Oumm wilve die buraen d pr g coal he or She did cat build or improve for me
purpcee ole) lssumm Fee $15.00
I,he oer of me do ,am exclusrvdy contracting with licensed contractors aIesYe Date TOTAL FEE �'�mneIM1K1 project I n 7pe4 Business am Prolessions Cade The Contractors4cedmladoeami piywmmnmwPropertywhabwilasorimpmves Merlon,antlREADC NDITIONS BELOWwho contr for a protects with a contmctor(s)Iimnee pursuant to me Contramors The work aYtherlZetl b Issuance of this permit Is ION
Lxenss L. antl uletlOns let lonh 1n the ordinances antl amendments 1 to of thei the miss
Ciry o1 EI
Iamsumr Sae_ B 8 Pc I-cols reason Segundo.and the laws of the State of California in regard to such work,and
Owns, all amendments hereto
This permit becomes null and void if work Is not cornmenced within one
CONSTRUCTION LENDING AGENCY hundred eighty(1 e0)days from data of issuance,or if work is suspended at
WI twreby anion weer pruay ofprjury Mal mere a a conetrucuon lowing agency for any time during construction for the same period of time,or it any work is done
2 the prfomarbe o1 the wont 1 la period 1 roved(Sec 3097 Ca,C) in violation of the City Ordinance or State laws governing same
W Lmtlers Ndta
VALIDATION
LerWers Address
Distribution PINK (Dept) YELLOW (Applicant) dos FORM P40B nev 1/g5
INSPECTION - RECORD
APPROVALS
DATE INSPECTOR'S SIGNATURE DATE INSPECTORS SIGNATURE
SHOWER PAN HOT WATER HEATER
SEPTIC TANK PLUMBING FIXTURES
SEWER GAS TEST
UNDER FLOOR WORK UTILITY CO NOTIFIE
ROUGH PLUMBING
GAS PIPING
GAS VENT I IFINAL
REMARKS