HomeMy Public PortalAbout6227 SULTANA AVE_Plumbing__ ',WORKERS' COMPENSATION DECLARATION APPLICAT90N FOR PLUMBING PERMIT
•}r hereby•bffirm that I'hove a certificate of consent to self 76A667A
jnsure;.or.a certificate of Workers'Compensation Insurance, CE 817(REV. 10/81)
or a certified co thereof Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
h��`oo3o�—boOSp y T/nafyb�D9�'1t,�'� cit
o is No. Com an �
❑ Certified copy is hereby furnished. BUILDING
FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS l S L<AA14
Certified copy is filed with the county building inspec-
tion department NUMBER FIXTURE OR ITEM @ FEE
p LOCALITY
Date Appligant WATER CLOSET1,10NEAREST
CERTIFICATE OF EXEMPTIOeRRANCE
ORKERS' BATH TUB CROSS ST.
COMPENSATION OWNER
(This section need not be completed if the work involved by SHOWERi90 MAIL
the permit is for one hundred dollars($100)or loss.) LAVATORYADDRESSO
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK 00 CITY G ' ® TEL.NO. Q s
so as to become subject to the Workers'Compensation Laws. A DISHWASHER
CONTRACTOR i
Date Applicant CLOTHES WASHER 00
Yqa W,
NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY TEL.NO.
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. r/ OCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS t o/)m
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINALDATE � � VAL ATION
License Number 4%�g� Lic. Class,�j2� �
FIN 11M
Contractor Date BY
t=
I am x mpt under Sec. �
B.BP. . for this reason ;2 3 3 9 6 A
Plan check fee 110
Date: # 0 0 0 0 0 5
TOTAL FEE
PLUMBING PERMIT ISSUING FEE$
Signature O I o o 9 4 5 0
SINGLE FAMILY Plan check applicant o 0 o 9 4 5 0
U
HOME OWNER-BUILDER DECLARATION Name 1 1.05-85
1 hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business and
Professions Code): City Tel. No.
❑ 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).
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
Signa of Permittee Date