HomeMy Public PortalAbout5847 SULTANA AVE_Plumbing__ i WORKERS'COMPENSATION DECLARATION 76AG07p 1
;I hereby affirm that I have x certificate• of consent to self CE 111712-801 A P P L I C A T I'O N FOR. !PLUMBING PERMIT
insure,or a certificate of Workers'Compensation Insurance,or
'a certified copy.thereof Sec.3800,Lab.C,) ���LLLYYY
: —j COUNTY OF LOS ANGELES BUI WING AND SAFETY
Poli ihpany 1
Certified.co•py is hereby furnisheW. FOR APPLICANT TO FILL IN (PRINT OR 1YPE) BUILDING `
ADDRESSP
Certified copy.is filed �2z
' lding inspection NUMBER FIXTURE OR ITEM • FEE
e m f
LOCALITY
Da t"Tmss— tlpplic nt WATER CLOSET t
NEAREST
i BATH TUB CROSS ST..
! CERTIFICATE-OF EXEMPTION VROM WORKERS'
I COMPENSATION INS.URAN.CE SHOWER' OWNER
l ; . . MAIL
' LAVATORY
i(This section need not be completed N the work involved ADDRESS.-I's-
;by
DDRESS �.
iby -the permit is for one Hundred dollars ($100).or less.) SINK, N
. L.
I. certify that, in the performance.of the work for which this E . � V
DISHWASHER
-. _ _ .... CIT
Y T �Z
'Permit is issued I shall not employ any person in any manner CONTRACTOR.
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so as to,.become.subject•to the Workers'Compensation Laws. CLOTHES WASHER
ADDRESS.
Date Applicant
SWIMMING POOL RECEPTOR V
'NOTICE TO APPLICANT: If„after making this Certificate of CITY TEL.NO.. �p
Exemption, you, should become subject, to. the Workers' LAWN SPRINKLER SYSTEM STATE IC. U)
;Comp'ensation provisions of the.Labor Code,you .N
u must forth- LICEN$E .O ACL S Com /
;with cortiply with such provisions -or this permit' shall be WATER HEATER e
�deemed'revoked. r DIST CT NO., P .O ESSE, Y I
GAS SYSTEM OUTLETS
LICENSED CONTRACTORS•DECLARATION OUTLETS OVER
hereby. affirm that I am licensed under provisions of Chapter a PE•R SYSTEM
ascommencing with Section'7000 -of Division 3 of the Busi- iF•IN'AL
s and.Professions Code, and my license is in full force and DATE r VALIDATION
ffect. ,,
4L4, _
cen m Lic.Class C.__
V. - BYNA
o" ata '��"�� Y
I am exempt from the licensing requirements as I•am a
licensed, architect. or a registered professional engineer PLUMBING PERMITG9
acting in 'my professional capacity (Section 7051, Bus- 'ISSUING FEE$
in'ess and Professions Code). TOTAL FEE
or Reg.No. Date Plan check applicant
HOME OWNER-BUILDER DECLARATION Name. r
hereby affirm that I, am exempt-froth Address the. Contractor's
rcense- Law for the following reason (Section;7031.5, Busi City Tel.No..
ess and Professions Code):
I, as owner of the property, am exclusively contracting „ 4 0 '9 A
with licensed contractors to construct. the project
(Section 7044,Business and Professions Code).
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CONSTRUCTION LENDING AGENCY c c 0"00 0 0'
I.Ihareby affirm,that there is a construction lending agency
for the performance of the work for which this permit'.fs
1.
issued(Sec.30.97,Civ.C.) 00
.. � .' ,0a 0 a
Lender's Name „ O 7-81
Lender's Address
I:certify that'I have read this application.:and state that the i
above information is.correct.I agree to comply with.all-County
ordinances. and State laws regulating Plumbing, and hereby I SEE REVERSE FOR EXPI:ANATORY LANGUAGE
aut sentatives of this County to enter upon the
tO.OV6-mentioniil property for inspection purposes..
ignat- of Par a Date