HomeMy Public PortalAbout6132 SULTANA AVE_Plumbing__ RKERS'COMPENSATIONDECLf cons
o" 20-0026 DPW 4
$N APPLICATION FOR PLUMBING PERMIT
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4-rt^e ebyr affirm that I hav^e a certific8te of consent to self in= 76A667A
sure,or.a,cer14fif62vWof Workers'Compensation-Insurance,or a CE 817(REV.8/86)
certifieiTcopy thereof'(Sec. 3800, Lab. C.);• LLLJJJ
` ' COUNTY OF LOS'ANGELES DEPT. OF PUBLIC•WORKS
Policy No.- Company
0 Certified copy is'kereby furnished. BUILDING
FOR APPLICANT TO FILL.IN(PRINT OR TYPE) <°'
Certified copy is filed with the county building inspection ADDRESS ��3 /�• _dl 7' N�
NUMBER FIXTURE OR ITEM LOCALITY
deparfm..ent. @ FEE
Date / �(,(0 WATER CLOSET(TOILET)
Applicant '' NEAREST.
`
' CERTIFICATE, BATH TUB 0 CROSS,ST.OF EXEMPTION FROM WORKERS' " ' v�
COMPENSATION INSURANCESHOWER
0 NER-'
1 Q (N • CH&V&
(This section'need not'be eompleted IF the work involved by MAIL
the permit.is For one hundred dollars(6100)or less.)' LAVAT.ORY ADDRESS
I certify thaf in the performance of the work-for which this per- +
mit is issued, I shall not employ any person.in any mariner so SINK',•' CITY TEL_NO.
as to become'subject to'the Workers'Compensation Laws. DISHWASHER
CONTRACTOR
Applicant
CLOTHES-WASHER
NOTICE TO APPLICANT: If, after making this Certificate of Ex- ADDRESS
emotion,you should become subiect fathe Workers'Compdn-, ` SWIMMING POOL RECEPTOR
CITY •TEL. NO.
+sation provisions of the L615or Code,youmust forthwith comp- LR,VyN.SPRINKLER SYSTEM - ' ''
ly with such provisions or this permit.shall.be deemed.revok- STATE V LIC..
ed. WATER HEATER LICENSE.NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRIC�1
5 '0. PROCESSED
I'hereby'affirm that I ani licensed under provisions of Chapter J GAS SYSTEM OUTLETS /
9(commencing with Section 7000)of Division 3 of the.Business ,t• OUTLETS OVER �•�
fed Professions-Code, and my license is in full force and ef- 5 PER SYSTEM- FINAL / _ VALIDATIO
DATE IL
O
License Number: Lic. Class 0
FINAL -
ContraDate BY O
I am pxerriot'under SecI ..
B.&P.C. for This reason y
Plan check fee, W.
Date:. A93 -YA
PLUMBING PERMIT,ISSUING FEE$-
Sighature # o:o. o•o 0 5
i TOTAL FEE
SINGLE FAMILY,
HOME OWNER-BUILDER DECLARATION' Plari check.applicant ( ° 6.765
I hereby affirm that i am exempt.ffom the Contractor's License Name. ) o o -d7&50'
Law for the-following reason(Section 7031.5, Business and .
Professions Code),;- IAddress +• .0 4,.0$`�
I
I, as-owner of the-property,..will do the work and the City. , Tel. No.
structure.is not intended or offered.forsdle(Section 7044,
Business and Professions.Code).
CONSTRUCTION LENDING AGENCY ,
I hereby off irm that there is a construction fending agency for
the performapce 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 i
authorize;reptesentatives•of this County to.-enter upon the
above-mentioned Propert .a r inspection purposes.
SEE REVERSE'FOR EXPLANATORY,LANGUAG'E
,Signature of-Permittee, Date.. r y.