HomeMy Public PortalAbout6027 SULTANA AVE_Plumbing__ �•r V WpRKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
bRf irm that I have a certificate of consent to self in- 20-OD26 DPW 4/87
'. y f f 76A667A
f,
sn e,or a certificate of Workers'Compensation Insurance,or a CE 817(REV.8/86)
certified copy thereof(Sec. 3800, Lab. C.) . 'fl
Policy No. Company. COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Certified copy is hereby furnished. L BUILDING
FOR APPLICANT TO FILL IN(PRINT OR TYPE) /1 f' r41675 NA
Certified copy is filed with the county building inspection ADDRESS E0�Z
department. NUMBER FIXTURE'OR.ITEM @ FEELOCALITYLOCALITY
Date Applicant WATER CLOSET(TOILET) • 6 v NEAREST �� c1 r
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB q_,Sk0UW /1 CROSS ST.' /f1IBA�AI �•
COMPENSATION INSURANCE SHOWER If OWNER C-4el
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS 0;C7 IV, .5'V1T N
I certify that in the performance of the work for which this-per-
SINK CITY T1 G Ca TEL.NO. _ o
mit is issued, I shall not employ any person•in any m ner so
as.to beco a subiect to the Workers' ompensation ws. DISHWASHER'
CONTRACTOR _
Date �� Applicant C3 CLOTHES WASHER
NOTICE O A PLICANT: If, after ma g this Certificate Ex- ADDRESS
em tion,you-should become sub'ec the Workers'Com en- SWIMMING POOL RECEPTOR
P Y I P CITY TEL. NO.
sation provisions of the Labor Code, ou must forthwith comp- LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok- STATE LIC.
ed: - WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO'. P ESSED
1 hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM. OUTLETS
9(commencing with Section 7000)of Division 3•of the Business OUTLETS OVER '��
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL VA DATION >-
fect. DATE IL
O
License Number Lic. Class (�
FINAL
Contractor Date BY p
• F-
❑• I am exempt under Sec. W
IL
for this reason1 0 Q 9 A
Plan check fee rn
Date: PLUMBING PERMIT ISSUING FEE$ #'6 0 0;o 0 5
Signature
TOTAL FEE ) .o 628,50
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Plan check applicant "0 0'0 2&5 0-5
I hereby affirm that I am exempt from the Contractor's License Name
Law for the following reason (Section 7031.5, Business and 1 0 2 7..c-8 8
Professi6ns Code): Address
491, as owner of the property, will-do the work and the City Tel. No.
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 iriformation.is correct. I agree to comply with all Counfy
o inances and State laws regulating Plumbing, and hereby
a thorizerepres ntatives of this County to enter upon the
a ve-mentione property for inspectio .purp ses.
d l� 8f0 SEE REVERSE FOR EXPLANATORY LANGUAGE
I nature of Permitt - Date
O KrERS'COMPENSATION DECLARATION
4Fi that I have a certificate of consent to self in- 20-0026 DPW 4/87 APPLICATION FOR PLUMBING PERMIT
sure.,bY 76A667A
sure,or a certificate of Workers'Compensation Insurance,or CE 817(REV.8/86)
certified copy thereof(Sec. 3800, Lab. C.)
Policy No. _ Company COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
F1 Certified copy is.hereby furnished. BUILDING
FOR APPLICANT TO FILL IN(PRINT OR TYPE)
Certified copy is filed with the county building inspection ADDRESS �OZ•7 /llrr Sul &4'_`,
department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY '/^;''�
Date Applicant WATER CLOSET(TOILET) NEAREST �,�
CERTIFICATE OF EXEMPTION FROM WORKERS' $ATH TUB CROSS ST. C
COMPENSATION INSURANCE SHOWER OWNER �S C I
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS �(�� /v
I certify that in the performance of the work for which this per-
mit is issued, I shall not employ any personL in an manner so SINK CITY TEL.NO.
as to become sub'ect to the Worker' ens .i n Laws. DISHWASHER
� CONTRACTOR
Date-Lo Applicant CLOTHES WASHER
ADDRESS
NOTICE T6 AP ICANT: If, after m ng this Certificat of Ex= i
emption,you should become suble to the•Workers'the - SWIMMING POOL RECEPTOR CITY T
sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok- STATE, LIC.
ed. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of'Chapter GAS SYSTEM U T' 6 46) y
9(commencing with Section 7000)of Division 3 of the Business: OUTLETS OVER
Z —
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINAL
� - .6 VALID ION
fect.
License Number Lic. Class O
Contractor Date V
209la0A.
I am exempt under Sec. W
B.BP.C. for this reason ► # o o'o o a 5
Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$ G S I o o.1 6 5 0
Signature TOTAL FEE o 0 0''1 () 5 0 5SINGLE'FAMILY � •
HOME OWNER-BUILDER DECLARATION Plan check applicant
(120=•88
I hereby affirm that I am exempt from the Contractor's License Name
Low for the following reason (Section 7031.5, Business and i
Professions Code): Address
as owner of the property, will do the work and the City Tel, No;
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.).
i
Lender's Name
Lender's Address I
I certify that I have read this application and state that the
above information is correct,I agree to comply with all County
4.be-mentioned
antes and State laws regulating Plumbing, and hereby
rize represents ves of this County to enter upon th
pr erty for inspection pur ses
SEE REVERSE FOR EXPLANATORY LANGUAGE
lure of Permittee TDole