HomeMy Public PortalAbout5057 SULTANA AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION200026 APPLICATION FOR PLUMBING PERMIT
I hereby, affirm that i have a certificate of consent to self m- 7A�4/90
sure,or a certificate of Workers Compensation Insurance,ora cs I -
certified copy thereof (Sec 3800, Lab C ) Iul
.ci- Company��A, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No I as�
RICertified copy is hereby furnished -
❑ FOR APPLICANT TO FILL IN(FAINT OR TYPE) BUILDING
Cenihed copy is filed with the county building inspection AtJDRESS
deportment NUMBER FIXTURE OR ITEM ® FEE LOCALITY
Date Applicant pqqC WATER CLOSET(TOILET) ,/Q NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS
ST
COMPENSATION INSURANCE SHOWEROWNER
(This section need not be cosnplafad if the work Imrohred by MAIL
the Permit is for one hundred dollars($100)or less) LAVATORY AWRM
I certify that in the performance of the work for which this per- SINK - CRI, TEL NO 94mit is issued, I shall not employ any person in any manner so
m to become subject to the Workers'Compensation Laws DISHWASHER
CONTRACTOR L
Date Applicant norHEs WASHER ADDRESS N- 4TCAAJ7:C g LLVI p 207 .
NOTICE TO APPLICANT If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR q
emption you should become subject to the Workers'Compen- Cm TEL No ay2'db(F
sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEMS
Iy with such provisions or this permit shall be deemed revok- STATELAC
ed r WATER NEATER LICENSE NO &ASS '
LICENSED CONTRACTORS DECLARATION ( GAS SYSTEM OUTLETS NO > PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter
9(commencing with Section 70(X))of Division 3 of the Business OUTLETS OVER
and Profess.am Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VALIDATION
fect NOSE BIB DATE
License Number�1.2_L�.2_Lic Class
FINALV
5
Contractor Date 3-ta-gre - BY ACCfT.A .y}cc
❑ 1 am exempt under Sec Q .�M7j 172."•j
B 8P C for this reason Plan check fee ► 1 ITEMS �lu
Date PLUMBING PERMIT ISSUING FEE$ TOTAL 172. 21EP
Signature TOTAL FEE CHECK 172.20
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Pion check applicant .[ro
I hereby affirm that I am exempt from the Contmctorr s license Name _
Law for the following reason (Section 7031 5, Business and 0000-0001 3/12/94
Professions Code) Address
1, as owner of the property, will do the work and the City Tel No $254 1 AM 9:19
structure is not intended or offered for sale($action 70",
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
(Sac 3097, Ctv C )
Lender's Nome
Lender s Address -
1 certify that 1 have read this application and state that the ,
above mformahon is correct I agree to comply with all County _
ordinances and State laws regulating Plumbing, and hereby
outhorixe representatives of this County to enter upon the
above-menhoned ropert4ity for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of P ee Date