HomeMy Public PortalAbout6105 SULTANA AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION i APPLICATION FOR PLUMBING PERMIT
I hereby affirm That I have a certificate of consent to self 76A667A
insure, ora certificate of Workers'Compensation Insurance, I CE 817(REV: 10/81)
or a certified co y thereof,(Sec. 3800, Lob.C.) -r
j ` i I COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy I ompany• � `a j f= ( j.0 70%r
Certified copy is hereby furnished. BUILDING 1
FOR APPLICANT TO FILL IN(PRINT OR TYPE) t Certified copy is filed with the county buildinglrispec- ADDRESS r/1 ..-' z %/`�,• ,s-%
tion'de anent i NUMBER FIXTURE OR ITEM @ FEE fr- J ,✓"
s .y f LOCALITY ( � 1t r�I Z/
Data f Applicants` 'cr' WATER CLOSET NEAREST t 4
ar` tt.:%�ir,+�:r(.•C
• CERTIFICATE OF EXEMPTION F OM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE SHOWER OWNER
(Th(s section need not be completed if the work involved by
the permit is for one hundred dollars(;100)or less.) MAIL
LAVATORY ADDRESS �� ✓r' J, y'/G
.l 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. NQ,�ee,• -!f•�
so as.to become subiect to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR
DateApplicant' - CLOTHES WASHER ADDRESS `r.'
NOTICE TO APPLICANT: If; after making this Certificate of SWIMMING POOL RECEPTOR �
Exemption, you should become subject to the Workers' ' •-•
CITY r f r TEL. NO-`-`
-"..., r V
Compensation provisions of the Labor Code, you must forth- ice?+%J�.°=:,;,11 e.+ c�z '
LAWN SPRINKLER SYSTEM
with comply with .such provisions or this permit shall be STATE , LIC.
deemed revoked. WATER HEATER LICENSE NO.. _ �� s! CLASS e6r' �
LICENSEDCONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY'
['hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(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 VALIDATION O
v
License Number Jic.Class [ � r` Ti�J'f`i /• DATE Lu
d FINAL
Contractor Date. BY
a
I ani exempt under Sec. B
B.&P.C. for this reason O
Plan check fee ► n.
Date: W
• PLUMBING PERMIT ISSUING FEE$
Signature- f` HIT
TOTAL FEE
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name �• ,i.,{*1!1,t;•; ``rxl
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and Address
Professions Code.):' City Tel. No.
Ell, as owner of the property, will do the-work and the �)I F '( •`�
structure is not intended or offered for sale (Section ► 1
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. 300, Civ. C.).
Fender's Name
Lender's Address
t 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 represento$yes of this County to enter upon the ;
t babe-mentioned property for inspection!purposes.3,� .oT �/' �+ �y••�„ �,•' SEE REVERSE FOR EXPLANATORY LANGUAGE
Sign re.of Permittee Date