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Home My Public Portal About10303 KEY WEST ST_Plumbing__ WORKERS"COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a certificate of consent to self 76A667A insure, Ar a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81) or a certified�o y thereof Sec. 3800, Lab. C.)�/,.D)p�/ A� COUNTY OF LOS ANGELES BUILDING�^AND SAFETY 73 ,0 �5-�©© pony�JJJ-y GV/U/r- ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING R1Certified copy is filed with the county building inspec- ADDRESS tion !— department. NUMBER FIXTURE OR ITEM a FEE LOCALITY Y'l /�f� Date i/ 91_ Applicant /IfWATER CLOSET ✓`� NEAREST nn CERTIFICATE OF EXEMPTIO?1RANC ORKERS' BATH TUB OO CROSS ST. 9 K COMPENSATION E SHOWER y Do OWNER (This section need not be complework involved by 7 ,l1 MAIL / ♦ p the permit is for one hundred dollars ($100)or less.) LAVATORY 0 ADDRESS (p a/- �G I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK 9,0 CITY /? j TEL. NO. so as to become subject to the Workers'Compensation Laws. � O DISHWASHER tp 00CONTRACTOR DateApplicant CLOTHES WASHER ADDRESS Q NOTICE TO APPLICANT: If, after making this Certificate of `C• Widnob Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR CITY j /!� TEL. N q Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM / `G with comply with such provisions or this permit shall be STATE LIC. deemed revoked. WATER HEATER 00 LICENSE NO. CLASS C LICENSED CONTRACTORS DECLARATION /�. DISTRICT yO. ESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 (' GAS SYSTEM OUTLETS V 1// (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER t VV and Professions Code, and my license is in full force and effect. 5 PER SYSTEM FINAL — — VAL TION License Number / q� � Lic. ClassCY� DATE � � FI Contractor Date — ElI ammpt under Sec. @, B. for this reason Poo. .2 check fee Date: 2 7 1.7 A PLUMBING PERMIT ISSUING FEE$ 5O Signature $�� #-o,o 0 0 0 5 TOTAL FEE qq Plan check applicant I - 94,50 SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name o ° ° 9 i,5 0.6) I hereby affirm that I am exempt from the Contractor's License Address Law for the following reason (Section 7031.5, Business and 0 8. 1 4� 8 5 Professions 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 to enter upon the above- boned prop for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Sig lure of Permittee Date