HomeMy Public PortalAbout5830 SULTANA AVE_Plumbing__ Z' `WORKERS"CPMFfNSATION DECLARATION
�. ry , APPLICATION FOR FLUMBING PERMIT
lig 46*iaffl�M ingt I have a certificate of consent 'to self 76A667A
insure, or a certificate of Workers'Compensation Insurance, •CE 131.7(REV. 10%81)
or a certified'coy thereof(Sec. 3800, Lob. c.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
' ,.
Policy N S•87G,-72,-U panylnduS:tr`ial rade i.
❑'t Certified copy(s hereby furnished. 5
„■. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING.
Certified copy is filed with the county building inspec- ADDRESS. 8.30 Sultana Ave
tion department. NUMBER FIXTURE OR ITEM (� FEE LOCALITY
TempiL- city,,
WATER CLOSET
QaT'e .� .��/>�'�' Appl.i4gnt ZED LPta' NEAREST
j CERTIFICATE OF EXEMPTION.PROM WORKERS' �,
BATH TUB CROSS.ST.. . rTnosa
COMPENSATION INSURANCE OWNER
SHOWER
(This section need not be completed If the work involved by MAIL
the permit is for one hundred dollbrs,($100)or less.) 'LAVATORYADDRESS
I certify That in the-performance the work for which this -83G Sultana Ave.
6• Q0
permit is issued,,I shall not em Io an person In any manner SINK. CITY TEL NO. -^
p P Y Y P Y. ! '.
so as To become subject to the Workers'Compensation Laws. DISHWASHER
` CONTRACiO
Date Applicant 1 CLOTHES WASHER ADDRESS
NOTICE'TO APPLICANT: If; after making this:'Certificate of !
Exe.mptio.n, you.should' become sub'ect to the Workers' SWIMMING PO L RECEPTOR
Y I '' _ CITY .. TEL.NO. 51-1
C.ompensa.tion provisio.ns•.of the'La.bor Code; you must forth- LAWN SPRINKLER SYSTEM
with comply with such ,provisions. or .This permit sha.11''lie STATE ., ` LIC.
deemed revoked. Z WATER HEATER
LICENSE NO.�. CLASS.
-LICENSED CONTRACTORS DECLARATION DISTTRRI .Ng; OCESSED BY
1 hereby affirm that,l am licensed under provisions of Chapter 9 II GAS SYSTEM' U U 1Y1
(commencing With Section 7000) of Division 3 of the Business OUTLETS OVER916
OUTLETS
and Professions Code,and my'license.is in full'force.and effects 5PER SYSTEMFINALVALI ION
DATE' V
I License Number 38'6'678• Lic..Class- ..C36 69
1 , G' -
• •'FINA
I Contractor.TTri i 37er"l 'R3.hCrpte T7 5��R S BY 11
❑ i
6 am exempt under Sec.
!II' B-.BP:C. for,this-reason
P,
Ion check fee
Date: 1
o o000��
PLUMBINGPERNT ISSUING:FEE.$
Signature
,
I o'o
TOTAL FEE.
Plan check'applicont,
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name. # o o .0 0 0 5
(hereby offirrn That f am exempt'from the Contractor's.License , .
Law for The following reason (Section 7031.5; Business and '.Address ( a o 5 .5 0
Professions Code): . City Tel. No. 0 0 0'5 7,'7 5 5
❑ I, as owner.of,the'property, will do the work and the
structure is not intended or offered for sale (Section o 2.2 8-8 5
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 flus permit is.issued;
(Sec: 8097C&IV C.). ,
'Lender's:Name. i }
Lender's•Address
I certify thaf I.have read this.application land state:that the
above information is correct. I agree to comply with all County
ordinances and State laws.regulating Plumbing,.and hereby
'• authorize tepre naive
'I of this County to. enter upon the l
above-mention property for inspection purposes. I SEE.REVERSE FOR EXPLANATORY LANGUAGE.
Si tune of Pe .ittee Date