HomeMy Public PortalAbout6155 1/2 SULTANA AVE_Plumbing__ VVO,RKERS,COMPENSATION DECLARATION l
I hereby, affirm that I have a certificate of consent to self in- jbq�jA PW 4/87 APPLICATION FOR PLUMBING PERMIT
sure,or a certificate of Workers'Compensation Insurance,or a 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. _ r
Certified co is filed with the count building p FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING (!�
o copy• y gins inspection ADDRESS
department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Date Applicant ( WATER CLOSET(TOILET)
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' B BATH TUBt) CROSS ST. (, �LG•l
COMPENSATION INSURANCE I SHOWER (J OWNER
(This section need not be completed if the work involved by MAIL
6-4
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS W1
1 certify that in the performance of the work for which this per-
mit is issued, I shall not employ any person in any manner so SINK CITY TEL. NO.j YV
as to become subject fo the Workers'Compensation Laws. DISHWASHER
CONTRACTOR
Date Applicant.__ 1L� CLOTHES WASHER
NOTICE TO APPLICANT: If,after making this Certificate of Ex- ADDRESS Ute✓'
SWIMMING POOL RECEPTOR
emption,you should become subject to the Workers'Compen-
CITY TEL. NO.
sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEM
ly with such provisions or this permit shall be deemed revok- STATE LIC.
ed. 9 WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. OCESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER (/
and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FDIAN + V DATION a
fect.
License Number Lic. Class 0
FINAL 0
Contractor Date BY 0
n o
I am exempt under Sec. V
l>" W
B.BP.C. for this reasonr a
Plan check fee z 9 8 4. 1 A CO)
Date: /
PLUMBING PERMIT ISSUING FEE$ l # o o o 0 0 5
Signature TOTAL FEE ( o o 5 8-5 0
SINGLE FAMILY Plan check applicant
HOME OWNER-BUILDER DECLARATIONo o o 5 8,5 0 35
I hereby affirm that I am exempt from the Contractor's License Name
Low for the following reason (Section 7031.5, Business and 6,09-88
Prof ssions Code): Address
I, as owner of the property, will do the work and the City Tel. No.
structure is not intended or offered for sale(Section 7014,
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 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-mentioned property for Inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee at