HomeMy Public PortalAbout6345 SULTANA AVE_Plumbing__ ,WORKERS'COMPENSATION DECLARATION APPUCATp0I4 FOR PLUMBING PERMIT
I hgreby affirm that I Acive a cbrtif!cote of consent to self 20-0026 DPW 6/87
itis�re, or a certificate of Workers'Compensation Insurance, 76A667A
or a certified copy thereof(Sec. 3800, Lob. 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 Inspec- ADDRESS
tion department. NUMBER FIXTURE OR ITEM FEE LOCALITY
Date Appligant WATER CLOSET NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATHTUB CROSS ST.
�� /T
-
COMPENSATION INSURANCE OWNER
(This section need not bo eomplotad If 4ho work involved by SHOWER �^1 f,
the permit Is for ono hundrad dollars($100)or loss.) LAVATORY 250
ADDRESS (pry �s�rr'9 it }I,ee/erC��
1 certify that in the performance of the work for which this y �gy ��� �` �8
permit is issued,1 shall not employ any person in any manner SINK I V CITY A� TEL.NO O
so as to become subject to the Workers'Compensation Law . DISHWASHER
��f� ,) J q CONTRACTOR
Date 6�(J' v pplicant V14G�t§1v 14, - CLOTHES WASHER ADDRESS o
NOTICE TO APPLICANT: If, after oking this Certificate of A Wit
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
TEL. NO.
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY
with comply with such provisions or this permit shall be I STATE LIC.
deemed revoked. WATER HEATER LICENSE NO. CLASS
LICENSED CONTRACTORS DECLARATIONDISTRICT PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETSAll
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER t
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL LIDt4TION pie`
DATE G
License Number Lic. Class 0
FINAL
Contractor Date BY 0
9
❑ I am exempt under Sec. W
B.BP.C. for this reason 1701
Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE
SINGLE FAMILY Plan check applicant 5
HOME OWNER-BUILDER DECLARATION Name ACCT.4
I hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business and 3307 °
Professions Code): City Tel. No.❑ 1 ITEMS I, as owner of the property, will do the work and the {�
structure is not intended or offered for sale (Section TOTAL 58 o IUD
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
�HE��i �+° �
1 hereby affirm that there is a construction lending agency for CHANGE 011
the performance of the work for which this permit is issued °
(Sec. 3097, Civ. C.).
Lender's Name 0000-0001 7/20/90
Lender's Address
1941 1 AN 7 014
1 certify that I have read this application and state that the
above information is correct. I agree to comply with all County i
ordinances and State laws regulating Plumbing, and hereby 1
authorize representatives of this County to enter upon the
above-mentioned property for inspection purpos
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Per ittee Date