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Home My Public Portal About6019 SULTANA AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION 76AG67A „ I hereby affitm that I have a' certificate of consent to self ce e17 (z-66) APPLICATION FOR PLUMBING PERMIT. insure,or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY .Policy No. Conpany O Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING ADDRESS Certified copy Js filed with the county building inspection NUMBER FIXTURE OR ITEM ® FEE department. WATER CLOSET LOCALITY Date • Applicant NEAREST BATH TUB CROSS T. CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE SHOWER OWNER I L LAVATORY MA (This section need not be completed. if the work involved ADDRESS p f } by the permit is for one hundred dollars ($100) or less.) Js I N Ka CIT TEL.NO. 0 I certify that in the performance of the work for which this 0 permit is issued,, I shall not employ any,person in any manner DISHWASHER CONTRACTOR so as to become subject to the Workers'Compensation Laws. CLOTHES WASHER ADDRESS 0 Date Applicant SWIMMING POOL RECEPTOR NOTICE TO APPLICANT: If, after making this Certificate of CITY LEN LU Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM N Compensation provisions of the Labor Code, you must forth- STATE Z with comply with such provisions or this permit shall be WATER HEATER LICENSE NO. deemed revoked. �� DISTRICT NO. D BY u GAS SYSTEM .OUTLETS INCENSED CONTRACTORS DECLARATION OUTLETS OVER I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM 9 (commencing with Section 7000)of Division 3 of the Busi- FINAL '/ A JT ness and Professions Code,and my license is in full force and DATE (f A VALIDATt N effect. , License Number lFINAL c.Class., FI Contractor Date I am exempt from the licensing requirements as I am a Plan Check fee licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$ acting in-my professional capacity (Section 7051, Bus- iaess and Professions Code). TOTAL FEE i Lic.or Reg.No. Date Plan check applicant + HOME OWNER-BUILDER DECLARATION Name � I hereby affirm that I am exempt from the Contractor's Address / License Law for the following reason (Section.7031.5, Busi- Tel.No. ness and Professions Code):, ;?2822A I, as owner of the property, am exclusively contracting with licensed contractors to construct the project )1 0o a o o 5 (Section 7044,Business and Professions-Code). 2 0 - 1 6.00 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency o co 1 6,Q Q? , for the performance of the work for which this permit is issued(Sec.3097,Civ.C.). l Q28-80 Lender's Name 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 SEE REVERSE FOR EXPLANATORY LANGUAGE ordinances and State laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the above-menUGjred property for inspection purposes. / b r ignature of Per, • tee Date +WORKERS'COMPENSATION DECLARATION i o APDL OQ%TT ®N FOR PLUMBING PERMIT they by affirfi that I have a certificate of consent to self -6A667A insure, or a certificate of Workers'Compensation Insurance, CE 817(REV. 10/81) or a cert}bified c thereof(Sec. 38 Lab. C. COUNTY OF LOS ANGELES / BUILDING AND SAFETY Policy No.-Company 7500-84 . OW ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy is filed with the cou building inspec- ADDRESS ti*detment. NUMBER FIXTURE OR ITEM ® FEELOCALITYDate3 Appligan zt WATER CLOSET NEAREST ATE OF EXE PTI ROM RKERS' BATH TUB CROSS ST. / COMPENSATION SURAN E OWNER (This soction need not bo comploted IF the work Involved by SHOWER tho pormit Is for one hundred dollars($100)or less.) LAVATORY MAIL ADDRESS I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK CITY TEL. .7&5 7.i ff? so as to become subject to the Workers'Compensation Laws. DISHWASHER CONTRACTO � [ Date Applicant CLOTHES WASHER ADDRESShas t NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY I _1_A451;M TEL. NO �7 with comply with such provisions or this permit shall be STATE ,/6r / LIC. deemed revoked: WATER HEATER LICENSE N4 O. 7 {v CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS (/ (commencing with Section 7000) of Division 3 of the Business OUTOVERd and Professions Code,and my license is In full force and effect. 5 P TEM FINAL 12 VALIDATION ,L DATE is- License Number yS7 Lic.Class U �� FINA 1129Contracto.��Ir_ Date BY ❑ I am exempt under Sec. J 3 3 B.&P.C. for this reason Plan check fee 00. Date: PLUMBING PERMIT ISSUING FEE$ J a Signature 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. ❑ I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section 7044, Business and Professions Code). 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 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 repr9pentatives of this County to enter upon the above-menti d property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Sig a of Per flee to 76AG67A 1yE.¢1716)-'11/176 -- APPLICATION_ FOR..PLUM B ING .PERMIT r BUILDING AND SAFETY DIVISION FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING /,� NUMBER FIXTURE OR ITEM ® FEE ADDRESS WATER CLOSET LOCALI , BATH TUB NEAREST CROSS ST. SHOWER OWNER UA- Q LAVATORY MAIL.. ADDRES I SINK CITY O. DISHWASHER CONTRACTOR If CLOTHES WASHER ADDRESS SWIMMING POOL RECEPTOR CITY TEL.NO. LAWN SPRINKLER SYSTEM STATELIC. WATER HEATER. LICENSE NO.c�3. /) CLASS GAS SYSTEM OUTLETS DISTRICT NOO. A+�PROUP ZONE CE BY OUTLETS OVER 5 YSTEM INDUSTRIAL WASTE APPROVAL INSPECTION RECORD ub Plan check fee PLUMBING PERMIT ISSUING FEE$ '^ TOTAL FEE 1777-1 Plaan check applicant Plan APPROVALS DATE INSPECTOR'S SIGNATURE UNDER SLAB WORK Address ROUGH PLUMBING City Tel.No. GAS PIPING I HEREBY ACKNOWLEDGE THAT I'HAVE READ THIS APPLICATION AND STATE GAS VENT THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING. - HOT WATER HEATER I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR LICENSED AS PLUMBING FIXTURES REQUIRED BY LOS ANG C AND STATE.OF CALIFORNIA OR THAT 1 AM THE GAS TEST — -�� •�.q>" LEGAL OWNER OF;AN INTEND TO ESI THE ABOVE DESCRIBED RESIDENTIAL - PROPERTY. UTILITY CO.NOTIFIED SIGNATURE OF PERMITTEE FINAL PLAN CHECK VALIDATION cK. M.O, CASH PERMIT VALIDATION CK` M.D. CASH 6 6 OCT 20 5 b 1. 3.5 0 ,&t;d /f/• ,_ a , _ . 76A667A ICE 81719).-11/76 N V APPLICATIOFO PL MBING PERMIT R.EADY FOR F�NAJ QNpECV�(O BUILDING AND SAFETY DIVISION FOR APPLICANT TO FILL IN(PRINT OR.TYPE) BUILDING ,,,J NUMBER FIXTURE OR ITEM ® FEE ADDRESS 9 • .G7;44 , WATER CLOSET LOCALITY NEAREST BATH.TUB CROSS ST. SHOWER: OWNER y.d to d - LAVATORY ADDRESS 0 0eiT/T41. 3 SINK CITY �//gg nn�OccG� �� TEL.NO �f�J DISHWASHER CONTRACTcPACIFIC I,�qS' CLOTHES WASHER q��® ADDRESS �L E, GRAND All SWIMMING POOL RECEPTOR �� - 0 CITY LAWN SPRINKLER SYSTEM STATE WATER HEATER .LICENSE NO oy// CLASS GAS SYSTEM OUTLETS DISTRICT NO. GR P WN CES BY OUTLETS OVER s�Q / y. 5 PER SYSTEM INDUSTRIAL WASTE APPROVAL INSPECTION RECORD a &S eR [Planeck fee PLUMBING PERMIT ISSUING FEE$ TOTAL FEE - Plan check applicant Name APPROVALS DATE INSPECTOR'S SIGNATURE UNDER SLAB WORK Address ROUGH PLUMBING City Tel,No. GAS PIPING I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE GAS VENT THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL.000NTY ORDINANCES AND STATE LAWS REGULATING PLUMBING. HOT WATER:HEATER 1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR LICENSED AS PLUMBING FIXTURES REQUIRED BY'LOS ANGELES COUNTY AND STATE OF CALIFORNIA OR THAT 1 AM THE GAS TEST LEGAL OWNER OF,AND INTEND TO RESIDE IN THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. � /'1 UTILITY CO.,NOTIFIED ,• '• . SIGNATURE OFPERMITTEE L ` !C� FINAL ��- �;"��;" �,y-ed•�"�'�• q PLAN CHECK VALIDATION CK. M.O. CASH PERMIT VALIDATION (CK.) M.O. CASH r0E.0 �7 5 V 7.5 Gat' r - �.t �.• ®S