HomeMy Public PortalAbout5837 SULTANA AVE_Plumbing__ jC. J /-4f U
WORKERS'COMPENSATION DECLARATION i APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self 20-0026 DPW 6/87
insure, or a certificate of Workers'Compensation Insurance,) 76A667A City of Temples City 11 JI
or a certified coy�the�reo'f(Sec. 3800, Lob. C.) COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS
Policy too. 6969-0004MaC
❑ Certified copy is hereby furnished.
I FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspec- , ADDRESS 837 No. Sultana A
tion department. , NUMBER FIXTURE OR ITEM @ FEE LOCALITY
men3iu city
411-120 General •Ims 1, WATER CLOSET j
DateAppli4ant + �s I NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' I BATHTUB CROSS ST. Lao
Tia$ Dr.
COMPENSATION INSURANCE SHOWEROWNER J 'Go dOn e
viM
(This section need not be completed if the work involved byl MAIL
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS 5837 No. Sultiam Ava.
I certify that in the performance of the work for which this
permit is issued,I shall not employ any person in any manner, SINK CITY O _
so as to become subject to the Workers'Compensation Laws.l DISHWASHER
I CONTRACTOR Ce Co.
Date Applicant 55 CLOTHES WASHER ADDRESS West Blvd*
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, .you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth-' CITY TEL.NO ^2
LAWN SPRINKLER EM
ft
with comply with such provisions or this permit shall be. STATE p LIC. 'G
deemed revoked. I 1 WATER HEATER 6 LICENSE NO. 151839 CLASS C36
LICENSED CONTRACTORS DECLARATION DISTRICT NO. ROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM O ETS `D k
(commencing with Section 7000)of Division 3 of the Business) OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINA / VALIDATION
License Number 15 ,832 Lic. Class C36 i DA 1 ` C
C
Fl W 0 PrOYin Date �I 1 B O
Contractor / 3
❑ I am exempt under Sec. LL
B.BP.C. for this reasonG
I Plan check fee
Date:
PLUMBING PERMIT ISSUING FEE$ to M1 51D
Signature ,
i TOTAL FEE 1 3.4-56
SINGLE FAMILY
Plan check applicant o
� �
HOME OWNER-BUILDER DECLARATION Name ACC^r'A
I hereby affirm that I am exempt from the Contractor's License gddress � 1�}0 �
Law for the following reason (Section 7031.5, Business and- ITEMS
Professions Code): City Tel. No.
❑ I, as owner of the property, will do the work and the TOTAL 16 c 50
structure is not intended or offered for sale (Section
7044, Business and Professions Code). ® CHECK 16.50
CONSTRUCTION LENDING AGENCY I CHS 5
1 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.). MM-0001 8/ 7789
Lender's Name �
4939 1 Rn11.43
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 representative is County to enter upon the'
above-mentione� rty f inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
ignatu of Per a Date