HomeMy Public PortalAbout6335 SULTANA AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICA�� N FOR PLUMBING PERMIT
F'-"traffirm tAat'f have a certificate of consent to self 76A667A
a certificate of Workers'Compensation Insurance, CE 817(REV. 10/81)
'6T a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES � BUILDING AND SAFETY
Policy No. Company
❑ Certified copy is hereby furnished.
❑ I FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS
Certified copy is filed with the county building inspec-
tion department. NUMBER FIXTURE OR ITEM @FEE
LOCALITY —�
Date Appligant 2 WATER CLOSET (J NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' 2 BATH TUB L Q CROSS ST.
COMPENSATION INSURANCEi ' SHOWER OWNER
(This section need not be completed if the work involved by MAIL
the permit Is for one hundred dollars($100)or less.) LAVATORY aAA 1 ADDRESS
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK d CITYTEL.NO.
so as to become subject to the Workers'Compensation Laws. / DISHWASHER D
''1 CONTRACTOR
Date Iai -Applicant trlh �JWib r CLOTHES WASHER 0
NOTICE/TO APPLICANT: If, after making this Certificate of ADDRESS
SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY TEL. NO.
Iry
with comply with such provisions or this permit shall be � STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. OCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM 5 OUTLETS {� �k
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER ✓` (y IL
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL ® VA ATION 0
DATE
License Number Lic. Class B'
FINA 0
Contractor Date BY
I am exempt under Sec. �
B.BP.C. for this reason Date: r G Plan check fee 1
PLUMBING PERMIT ISSUING FEE$
Signature TOTAL FEE I!
SINGLE FAMILY Plan check applicant ;931 Q 9 A
HOME OWNER-BUILDER DECLARATION Name # 0 0 0 o o 5
Vhere y affirm that I am exempt from the Contractor's License Address
r the following reason (Section 7031.5, Business and 1 0Q50
ions Code): City Tel. No., as owner of the property, will do the work and the o 0 1 0 Q 5 0 cz
structure is not intended or offered for sale (Section
7044, Business and Professions Code).
Q 0 9—$5
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.
r SEE REVERSE FOR EXPLANATORY LANGUAGE
` . 0f„ o
Signature of Permittee Dat