HomeMy Public PortalAbout6155 SULTANA AVE_Plumbing__ WCIRKERS,COMPENSATION DECLARATION 666� PW 4/87 APPLICATION
PPLIC1TION FOR PLUMBING
elM®INV PERMIT
I hereby, affirm that I have a certificate of consent to self in- � AA
surg,or a certificate of Workers'Compensation Insurance,or a
f�
CE 817(REV. 8/86)
certified copy thereof (Sec. 3800, Lab. C.)
COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
Policy No. Company
❑ Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspection ADDRESS
department. NUMBER FIXTURE OR ITEM @ FEE
j� LOCALITY
Date Applicant WATER CLOSET(TOILET) 9. V NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB !� CROSS ST.
COMPENSATION INSURANCE v OWNER
l SHOWER
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars($100)or less.) LAVATORY 6 a ADDRESS It .
I certify that in the performance of the work for which this per- SINK
5
mit is issued, I shall not employ any person in any manner so do CITY ILI
.Il TEL. NO. EL-a/
as to become subjec to the Workers'Compensation Laws. DISHWASHER V
1./r7 / CONTRACTOR
Date O114 Applicant CLOTHES WASHER
ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
tion,you should become subject to the Workers'Com en- SWIMMING POOL RECEPTOR
em
P Y I P CITY TEL. NO.
sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok- STATE LIC.
ed. WATER HEATER LICENSE NO. CLASS.
LICENSED CONTRACTORS DECLARATION DISTRICT NO. OCESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS i^ �l
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER (f
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FI A .,�A h I TOV (DATION }
fect. T O
License Number Lic. Class V
FINAL
Contractor Date
BY
V, ;29840A
I am exempt under Sec. W
0 0 0 0 0 5 H
B.&P.C. for this reason Plan check fee
Date: I o 11 a50
PLUMBING PERMIT ISSUING FEE$
Signature TOTAL FEE ° ° 1 18,5 0 5
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Plan check applicant 0609-88
1 hereby affirm that I am exempt from the Contractor's License Name.
Law for the following reason (Section 7031.5, Business and
Professions Code): Address
1, 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
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 representatives of this County to enter upon the
above-mntioned pro erty for inspection purposes. i
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee -d6tt III,