HomeMy Public PortalAbout5955 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 a certificate of Workers'Compensation Insurance, ICE 817(REV. 10/81)
or a certified copy thereof(Sec. 3 . C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy 1Go.� �s3d Compan i
Certified copy is hereby furnished. BUILDING
❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS
Certified copy is filed with the county building inspec- NUMBER FIXTURE OR ITEM
tion department, @ FEE LOCALITY
Date q_3 Appli4ant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCEOWNER
(This section need not be completed if the work involved by SHOWER
the permit is for one hundred dollars($100)or less.) LAVATORY r MAIL ADDRESS
ADDRESSrldfa��1011 A-161
I certify that in the performance of the work for which this SINK r• CITY "fes TEL.NO.
permit is issued,I shall not employ any person in any manner ?
so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR
Date. Applicant CLOTHES WASHER ADDRESS /
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY TEL.NO z,
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. zw� CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT N PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 / GAS SYSTEM OUTLETS b
(commencing with Section.7000)of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL
(CR3G DATE '� 4W VALIDATION U
License Number 31912 Lic. Class gr
FINAL. f. O
Contractor C— Date /r� v BY • t i"`
4U
LU
I am exempt under Sec. �
h
B.BP.C. for this reason S Z
Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$ 1J
Signature 157)
TOTAL FEE
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business and
Professions Code): City Tel. No. `_ C(0 2 4 A'
❑ I, as owner of the property, will do the work and the }: 0 0 0 0 0
structure is not intended or offered for sale (Section
7044, Business and Professions Code). , no 0 7 Q 8'0
I
CONSTRUCTION LENDING AGENCY 0 0 0 J ` C
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued
(Sec. 3097, Cly. C.). Q7.28- 83-
Lender's Name
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
authorize representatives of this County to enter upon the
bove-mentione roperty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
7 Zf 3
Signature of P#fmifted Date