HomeMy Public PortalAbout10300 KEY WEST ST_Plumbing__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I havje a certificate of consent to self 76A667A
insure, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81)
-or aa��c((ertttiiffi�ied copy thereof (Sec.3800 Lab. C.)•���){ COUNTY OF LOS ANGELES BUILDING AND SAFETY
7'Fol icy N75. panY &,QTA,� j) �
❑ Certified copy is hereby furnished. BUILDING cJ
FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS
10
Certified copy is filed with the county building inspec-
tion department. NUMBER FIXTURE OR ITEM @a FEE
/V4 ,� yl- p� LOCALITY � , L
Date Applicantr iii) WATER CLOSET CJ® NEAREST
CERTIFICATE OF EXEMPTION OM WORKERS' BATH TUB Lt�� CROSS ST. Z
COMPENSATION I S RANCE �,o OWNER �-
(This section need not be complet if the work involved by SHOWER V�
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 ts
permit is issued, I shall not employ any person in any manner SINK v� CITY TEL. NO.
so as to become subject to the Workers Compensation Laws. DISHWASHER
®� CONTRACTOR 0 ��
Date Applicant CLOTHES WASHER omg_
fitx
NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS qy2
Exemption, you should become subject to the Workers' ` SWIMMING POOL RECEPTOR
CITY TEL. NO. �D1
i
Compensation provisions of the Labor Code, you must forth- qlgy .yQt
LAWN SPRINKLER SYSTEM g
with comply with such provisions or this permit shall be STATEQ �t�0 LIC
CLASS [iJ
deemed revoked. d WATER HEATER LICENSE NO. J c
LICENSED CONTRACTORS DECLARATION ®� DISTRICT NOi.., ROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code,and m license is in full force and effect. 5 PER SYSTEM
f}�(y y� is/�/_ DAT FINAL VA ATION 0
License Number—q20032 Lic. Class S�_
7 ,.� „n� FIN
Contractor Date iy BY.
I a e empt under Sec.
6.8 for this reason
Plan check fee
Date:
Signature PLUMBING PERMIT ISSUING FEE$ 5-0
TOTAL FEE119-1 50
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business and 2 2 7 1,6 A
Professions Code): City .Tel. No. # o o o o o 5
❑ I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section ® I o 0 9 II.5 0
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY o o o 9 4 5 0
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued D 1 4=P 5
(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 pr rt,for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Si ture of Permittee Date
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