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Home My Public Portal About6361 SULTANA AVE_Plumbing__ •', , s ' WORKER'S have a certiIONficate DECLARATIotconsentON 7OM67ADPW 9lee APPLICATION FOR PLUMBING PERMIT I hgteby,affirm,Yhat I have a certificate of consent to self insure, or a,�tificato of Worker's Compensation Insurance,or a certified copy thereof(Sec.3800 Lab.C.) COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV. } Policy NW Company ❑ Certified copy is hereby furnish \ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDINGADDRESS ElCertifiedcopy is filed w he county building inspection department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date Applicant 4 WATER CLOSET &C NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. COMPENSATION INSURANCE BATH TUB ASSESSOR (This section need not be completed if the work Involved by the ) SHOWER MAP BOOK PAGE PARCEL permit is for one hundred dollars($100)or less.) i LAVATORY D �� OWNER t, ' I certify that in the performance of the work for which this permit GO is issued, I shall not employ any person in any manner so as to MAILSINK �� ADDRESS b 4�i become subject to the Workers'Compensation Laws. DISWASHER �Q CITY r€M,QdE +r. TEL.NO.,k, y8f go gg Date Applicant CLOTHES WASHER CONTRACTOR NOTICE TO PPLIC NT: If, atter in-akInIf this CertificaIA_f 1- $ - em J S� Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code,you must forthwith comply with such T ADDRESS O a ' provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY TEL.NO. �' I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER �.S-O 41A eN�� /�3 &I (L d (commencing with Section 7000)of Division 3 of the Business and GAS SYSTEM OUTLETS V d CENSE NO. �JV gSTATE _4 CLASS LIC. G 0 Professions Code,and my license is in full force and effect. DISTRICT NO. PROCESSED BY 13:OUTLETS OVER Q O 5 PER SYSTEM License Number 3 Lic.Class C G V C FINAL /�_0 9�" VALIDATION a Contractor cJJ ctor � Date 4� � �� ❑ - �- Z r I am exempt under Sec. FINAL� gy fJ B.&P.C.for this reason Date: ,, Plan check fee 011. Signature T . PLUMBING PERMIT ISSUING FEE$ ❑ TOTAL FEE �� Q SINGLE FAMILY Plan check applicant =' !. HOME OWNER-BUILDER DECLARATION Name At--Toa'a , I hereby affirm that I am exempt from the Contractor's License Law -,z -� 140.50 p` �_• for the following reason(Section 7031.5, Business and Professions Address .:30 f 140 o 50 Code): C F1 1, Tel.No. I E!I, I,as owner of the property,will do the work and the structure TOTAL $�� Is not Intended or offered for sale(Section 7044, Business o and Professions Code). , CHEa,LL ii33 t.•IL�ri1 1410Is5+f CONSTRUCTION LENDING AGENCY CHANGE o dl 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 7814 1 AM 11 o ij 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 001. 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 WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby-affirm that I have a certificate of consent to self in- I 76A6667A PW 4/87 sure,or a certificate of Workers'Compensation Insurance,or a CE 817(REV.8/86) certified c y e c. 3800, Lab. Policy Company COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Certified copy is hereby furnished. I FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING // 14a�7 %� �/�� ❑ Certified copy is filed with the c n y building inspection ADDRESS Zp �r�+1 t/V department. I NUMBER FIXTURE.OR ITEM @ FEE i WATER CLOSET(TOILET) LOCALITY �� Date Applicant NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE SHOWER OWNER (This section need not be completed if the work involved by MAIL a @ �the permit is for one hundred dollars($100)or less.) LAVATORY ADDRESS I certify that in the performance of the work for which this per- SINK mit is issued, I shall not employ any person in any manner so CITY TEL. NO, as to become subject to the Workers'Compensation Laws. DISHWASHER 1 CONTRACTOR ^% Date Applicant CLOTHES WASHER 7 �� NOTICE TO APPLICANT: If, after making this Certificate of Ex- ADDRESS • emption,you should become subject to the Workers'Compen- SWIMMING POOL RECEPTOR �d / CITY TEL. NO. sation provisions of the Labor Code,you must forthwith comp- LAWN SPRINKLER SYSTEM � ly with such provisions or this permit shall be deemed revok- STATE LIC. ed. WATER HEATER LICENSE NO. LICENSED CONTRACTORS DECLARATION DISTRICT NO. P SED BY Q Cr} I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLS G, r 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code, and my license is in full force and ef- 5 PER SYSTEM FINALVALIDATIO >_ tett. DATE/Z.—Z d License m r Lic. Class U FIN Contractor Date BY ) O E] I a exempt under Sec. t— WU a B.BP.C. for this reason I Plan check fee Date: PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Plan check applicant I hereby affirm that I am exempt from the Contractor's License Name Law for the following reason (Section 7031.5, Business and Professions 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 7044, Business and Professions Code). 904,54A CONSTRUCTION LENDING AGENCY ® # 0 0 0 0 0 5 1 hereby affirm that there is a construction lending agency for 002250 the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). 0 a'o 2 2 5 0 53 Lender's Name 0 8 17,-88 Lender's Address I certify that I have read this application and state that the above mf ation is correct. I agree to comply with all County ordin ces and State laws regulating Plumbing, and hereby auo ze representatives of this County to enter upon the a v - tinned property for inspectionpy�poses� r / d(/ !/ l!/II' SEE REVERSE FOR EXPLANATORY LANGUAGE Si ature of Permittee Date