HomeMy Public PortalAbout5953 SULTANA AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a. certificate of consent to self 76A667A
insure, or al certificate of Workers'Co ensation Insurance, CE 817(REV. 10/81);
or a ceritiiffled.copy thereof,(Sec. 38 , L'b. C.) COUNTY OF LOS ANGELES. BUILDING AND SAFETY
Policy No, �^ Company
❑ Certified copy is:hereby furnished. BUILDING
FOR.APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS
�* Certified copy is filed with the county building inspec-
,j"�' tion department. NUMBER FIXTURE OR.ITEM. FEE.
LOCALITY
Date. A li4ant WATER CLOSET
pP /� NEi4REST.
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB � CROSS ST.
COMPENSATION INSURANCE OWNER
(This section need not be completed if.the work involved by SHOWER
41
the permit is.for one hundred dollars($T00)or less.) LAVATORY MAIL
ADDRESS
I certify that in. the performance of the work for which this.
permit is issued', I shall not employ any person in any manner SINK CITY TEL. NO.
so.'as to become su.bject'to the,Workers'Compensation Laws: DISHWASHER
•CONTRACTOR
Date. Applicant CLOTHES WASHER ADDRESS /
NOTICE TO APPLICANT: It.after making this Certificate of
SWIMMING
Exemption,. you should become subject to the, Workers POOLRECEPTOR
CITY EL.NO, �
Compensation,provisions of the Labor Code., you must forth- / .
I with such LAWN SPRINKLER.SYSTEM
•with comply ' provisions. or.this permit shall be' ST ET S p Lit
deemed revoked. WATER'HEATER L NO,. ! LASS
`` LICENSE . C'
LICENSED CONTRACTORS DECLARATION b. DISTRICT NO ROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS —� r
(commencing with Section 7000) of Division.3f of the Business OUTLETS-OVER
and Professions Code,and m leen a is in..full force and effect.. I 5 PER SYSTEM
Y FINAL 0
VALIDATION
DATE
License Numb Lit. Class:
_
G GL ... FINAL L
BY f Date
❑ LU
1 am exempt under Sec.' y
B.&P.C. for this reason A "'
Plan check fee
Date:.
• ' PLUMBING PERMIT ISSUING FEE'$
Signature
TOTAL FEE �J .
Plan check applicant '
SINGLE FAMILY-
HOME OWNER -BUILDER DECLARATION ,'Name
I hereby affirm that I amexempt.fFom the Contractor's License
Address
'Law for the following:reason'.(Section 7031.5, Business and. - • • . .- - - s O 2 3 •
Professions Code):•
❑ City Tel. No. t o 0 0. ° o:
I, as owner of theproperty,ert , will do the work and'the2 o o TG 5'
structure is.not Intended or offered for sale (Section ' `
7044, Business and Professions Code). ®, Q'° ° �,
CONSTRUCTION LENDING AGENCY. J
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.): I
Lender's Name )
Lender'srAddress
1 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.regu.lating Plumbing, and hereby
authorize 'representatives of this County to enter upon.-the I
bove-mentioned •roperty for inspection purposes. }
SEE REVERSE FOR EXPLANATORY LANGUAGE
9f9ricit7ure of P':m.ittee Date. fl '