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Home My Public Portal About6314 SULTANA AVE_Plumbing__ ' WORKER'S COMPENSATION DECLARATION 200026 DPW 9189 ' I hereby affio that I have a certificate of consent to self Insure, 76M67A APPLICAT�ON FOR PLUMBING PERMIT or a certificate of Worker's Compensation Insurance, or a certified copy thereof(Sec.3800 Lab.C.) Policy No. 0- mpany ��jj��gg�� COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV. 'L3o ��J�"�� ertified copy is hereby furnished. BUILDING / y j FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS 6 514- 5t 1,7, A/,4 Certified copy is filed with the county building inspection department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY �✓JG� Date �3 9� Applicant/-�� °moi'• ' WATER CLOSET ,e6 NEAREST CROSS ST. CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB ASSESSOR COMPENSATION INSURANCE (This section need not be completed if the work involved by the SHOWER MAP BOOK I PAGE PARCEL permit is for one hundred dollars($100)or less.) OWNER A4A e AIAS. W10A1�s I certify that in the performance of the work for which this permit LAVATORY /' / y�B /i `�G F#-- is issued, I shall not employ any person in any manner so as to SINK ADDRESS (1J�/� S �/i7�77 /4f/G/ AIL become subject to the Workers'Compensation Laws. DISWASHER CITY �� TEL.NO. Date Applicant CLOTHES WASHER NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOR / ®ifs Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR ADDRESS 0.3 r �4 provisions of the Labor Code,you must forthwith comply with such provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY �/- /� TEL.NO Zl3 s/� a I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER v (commencing with Section 7000)of Division 3 of the Business and GAS SYSTEM OUTLETS STATE E NO. •JQI��/7 LIC. � Q Professions Code,and my license is in full force and effect. DISTgICT NO, D BY Q OUTLETS OVER a/ �(J� Q 5 PER SYSTEM License Number-�i�j 8♦'D� Lic.Class //n/�� //,,` FINAL 2 I Q U ContractorW�-i�coda , Date d DATE 7 l C VALIDATION �z ;`� a FINAL AA .l. T11 1 t.1:r Z ❑ I am exempt under Sec. BY B.&P.C.for this reason -s i.�AL 72-75 Date: Plan check fee CHECR 72.75 Signature PLUMBING PERMIT ISSUING FEE$ �� ® i 1444163E ❑ TOTAL FEE �s SINGLE FAMILY Plan check applicant i i#lisJ� {tl�� iti r' I hereby affirm that ha E m eexempt OWNER-BUILDER DECLARATION r' from the Contractor's License Law Name ZJ for the following reason(Section 7031.5, Business and Professions Address 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 nter upon t bove-mentioned pr ort for Inspection p rpo s SEE REVERSE FOR EXPLANATORY LANGUAGE 41 U11-00"V10— AZ gnature of Permittee Date WORKERS'COMPENSATION DECLARATION APPLICAVON FOR PLUMBING PERMIT I hehebyMoforrra that I have a certificate of consent to self 76A667A i'n grd, ora certificate of Workers'Compensation Insurance, CE 817(REV. 10/81) or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY 93No479702-OcSampany Fremont El Certified copy is hereby furnished. BUILDING FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS 6 314 la Certified copy is filed with the county building inspec- NUMBER FIXTURE OR ITEM Ave- tion department. @ FEE LOCALITY Temple Cit Date 11 30/93 Appli4ant-AAA Cond_ Air WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE SHOWER OWNER Won ' (This section need.not be completed if the work involved by MAIL ' the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS 6314 Sultana Ave. I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK CITY Temple TEL.NO. 285-0322 so as to become subject to the Workers'Compensation Laws. DISHWASHER CONTRACTOR AAA COnd Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of 10160 Valley Blvd. Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY El Monte �` NO'579-1800 with comply with such. provisions or this permit shall be STATE LIC. deemed revoked. WATER HEATER LICENSE NO. 293529 CLASS C20/10 LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY GAS SYSTEM OUTLETS I hereby affirm that I am licensed under provisions of Chapter 9 1 � � �°O� (commencing with Section 7000)of Division 3 of the Business OUTLETS OVER >_ and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL `466ATION IL License Number 2 93 52 9 Lic. Class r2 0/1 0 DATE ?7 O FINAL Im Contractor AAA Cond Air Date 1113 0/93 BY / V IT I am exempt under Sec. B.BP.C. for this reason Plan check fee � Date: PLUMBING PERMIT ISSUING FEE$ �� Signature TOTAL FEE 40 Plan check applicant _ SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Address --•(_s » Z. Professions Code): City Tel. No. ,rr ._ ❑ I, as owner of the property, will do the work and the _ structure is not intended or offered for sale (Section 'tom;5 hiL .£,j. 1 o 235 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY •��t 1' `°�' I hereby affirm that there is a construction lending agency for °'„i the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). Lender's Name `•)")` 33-.1 1 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 outhoriz a esentative of is County to enter upon the above- nti rop y r.1 s ion-purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE David Cross 11-30-93 Signature of Permittee Date