HomeMy Public PortalAbout6035 SULTANA AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hePeby affirm that I have a certificate of consent to self 76A667A
assure, or a certificate of Workers'Compensation Insurance, CE 817(REV. 10/81)
or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
PolicyNo.{ d309�'omponY _Z&W� 1
�
Certified copy is hereby furnished. i BUILDING
FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS
Certified copy is filed with the c unty building inspec-
tion depart ent. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
WATER CLOSET
Date Applicant &4NEAREST
CERTIFICATE OF EXEMPTION FROM ORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE OWNER
(This section need not be completed if the work Involved by SHOWER
the permit Is for one hundred dollars($100)or less.) LAVATORY MAIL
ADDRESS
I certify that in the performance of the work for which this
permit is issued,I shall not employ any,person in any manner SINK CITY V TEL.NO.
so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS
Exemption, you should become subject to the Workers'
SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY TEL. NV-71D
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS °—/
LICENSED CONTRACTORS DECLARATION �y � DISTRICT N� ROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM �C7[1TLET$ eo
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER 9,
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL D �.. VALIDATION
/
License Num er r��,�'��9'Lic. Class � � / -� 0
FINAL 0
� O
Contract a BY V
❑ I am exempt under Sec. i IL
B.BP.C. for this reason ►
Plan check fee -------_ �
Date: i PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name ?C J y
I hereby affirm that I am exempt from'the Contractors License Address
Law for the following reason (Section 703.1.5, Business and +` o o. 0 0 0 5
Professions Code): Citi Tel. No.
❑ 1 n o %l C..7�
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).
• r
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 N11111.above information is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
authori representatives of this County to enter upon the
enttoned pro ty inspe tion purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
f>
Signature of P rmittee ate
T6A-17 3.85
01138-17 3-99 F'OR 'PLUM.BING PERMIT
DIVISION OF BUILDING AND SAFETY
Deportment of County Engineer
County Of LOS Angeles BUILDING
WM.J. FOX. COUNTY ENGINEER ADDRESS
CASSATT b.GRIFFIN,SUPT OF BUILDING
LOCALITY
FOR APPLICANT TO FILL IN NEAREST
e CROSS ST.
OWNER �p DISTRICT O GROUP ZONE READY FOR INSPECTION
MAIL
ADDRESS
INDUSTRIAL
CITY TEL.NO. WASTE APPROVAL
PLUM ��/ INSPECTION RECORD
ADDRESS
CITY TEL.N e(O 0.7/6
LICENS O.
NUMBER TYPE WFIXTURF OR ITEM FEE f
WATER CLOSET (TOILET) $
BATH TUB
SHOWER
LAVATORY (WASH BASIN)
KITCHEN SINK
DISHWASHER
AUNDRY TUB OR TRAY
CLOTHES WASHER
TOTAL NO. @ 0.80 APPROVALS
GAS SYSTEM OUTLETS 1.00
DATE INSPECTOR'S SIGNATURE
�
WATER HEATER @ 1.00 / UNDER SLAB WORK
PERMIT 1 00
ROUGH PLUMBING
S
I o GAS PIPING
TOTAL FEE 09-
GAS VENT
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION HOT WATER HEATER
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING FIXTURES
PLUMBING.
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR GAS TEST
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF-
CALIFORNIA OR THAT 1T LEGAL OWNER OF THE ABOVE UTILITY CO..NOTIFIED
DESCRIBED RESIDENTIAL OP Y.
SIGNATURE FINAL ��S h � .;'Mz'zpi:: iU4
OF PERMITTEE
WILLIAM J.FOX.COUNTY ENGINEER VALIDATION R.A.WOOD.CHIEF PLEIG.INSPECTOR
,2:8s aA m15 3 2.00