HomeMy Public PortalAbout5842 SULTANA AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of cQ1sent tce self 76A667A
insure, or a certificate of Workers'Compensation Insurance, CE 817(REV. 10/81)
or a certified copy thereof(Sec. 3800, La . C.) COUNTY OF LOS ANGELES / BUILDING AND SAFETY
Policy NodsCAC-105&. 694pany A-
❑ Certified copy is hereby furni hed.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Sg..i
erti ied co y is filed with th c u fy ui i in pec- ADDRESS UU 4 i
tion epar ent. NUMBER FIXTURE OR ITEM @ FEE
LOCA
LFP ^
Date Appligant r WATER CLOSET
NEAREST 1 �'
CERTIF CATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE OWNER �$
(This section need not be completed If the work Involved by SHOWER
the permit is for one hundred dollars($100)or less.) LAVATORY MAIL.
ADDRES
I certify that in the performance of the work for which this p
permit is issued, I shall not employ any person in any manner SINK CITY �g TEL.NO.
so as to become.subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR S ,(
Date Applicant CLOTHES WASHER ADDRESS Zv(od f
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY TEL.NO. O)
with comply with such provisions or this permit shall be STATE �h�Si CLASS SS � "S6
deemed revoked. WATER HEATER LICENSE NO. V C
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED ey
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000)of Division 3 of the BusinessOUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL
` D ' VALIDATION u
License NumbercJ7•�b`t� Lic.Class
FIN Ills
ContractorDate �a BY
❑ I am exempt under ec. //, 7�3 sM
1 v J'
up
B.BP.C. for thi as n
Plan check fee ► �
Ll
PLUMBING PERMIT ISSUING FEE S d
Signature
TOTAL FEE 30 4}
Plan check applicant
SINGLE FAMILY s ',6 3.5 A
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Address ' o I o 0 0 o 5
Law for the following reason (Section 7031.5, Business and
Professions Code): City Tel. No. 2:o 0 3 0 5 0
❑ I, as owner of thero ert , will do the work and the r, _
structure is not intended or offered for sale (Section o 0 o j 5 0 V_
7044, Business and Professions Code). , 0 D 2 1 —F 4
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 r
#e' dress y
t I have read this application and state t at the ►
mation' orrect. I a ree to comply ith aluntynd St to ws eg luting Plumbi g, an hereby
prese tativ oft is County to nter ponthe
o d rope t fo n;pection obir
o oses. f
(f/ SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Da e