HomeMy Public PortalAbout10306 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, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81)
7or certified co thereoff((Sec. 3800,, Lab. C.) COUNTY yyp���y�y� COUNTY OF LOS ANGELES B ILDI GAN SAFETY
Fo-ficy 1.40. �aCompanYl 1J """/r 1 uc�7 L 4 ✓�
❑ Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING /
Certified copy is filed with the county building inspec- ADDRESS c
tion department. NUMBER FIXTURE OR ITEM t?n FEE
LOCALITY { GI
WATER CLOSET ' L
Date / Applicant NEAREST
CERTIFICATE OF EXEMPTIO OM WORKERS' BATH TUB Psi CROSS ST. IDR
COMPENSATION I S RANGE SHOWER OWNER 6 " pV,6�9-
(This section need not be complet d if the work involved by ®0
the permit is for one hundred dollars ($100)or less.) LAVATORY MAIL
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I certify that in the performance of the work for which this ADDRESS
permit is issued, I shall not employ any person in any manner SINK �� CITY • /r ��1 7?)rTEL. NO.
so as to become subject to the Workers'Compensation Laws. p DISHWASHER l9
Y CONTRACTORpeQ/,
Date Applicant CLOTHES WASHERI ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of t�V
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR CITYTEL. NO
Compensation provisions of the Labor Code, you must forth- Q=lQ o
LAWN SPRINKLER SYSTEM 6717
with comply with such provisions or this permit shall be STATE ,xr LIC. �g
deemed revoked. WATER HEATER LICENSE NO. L CLASS
LICENSED CONTRACTORS DECLARATION 00 DISTRICT NO R ESSE Y
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS OL7 C�
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER J
and Professions Code, and my license is in full force and effect. 5 PER SYSTEM
DATE ,FINAZ — 0� VAL ATION
License Number Lic. Class
FIN L
Contractor JJ)PDate f 1
b
❑ I amFforptthis
under Sec. c71,9A
B.BPreason
Plan check fee # ° ° ° ° ° 5 g
Date: 10.
PLUMBING PERMIT ISSUING FEE$ I - 91,50
Signature
TOTAL FEE aq
o o o 9 1L 5 0 t=a
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name Q S 1 G S 5
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I hereby affirm that I am exempt from the Contractor's License Address
Law for the following reason (Section 7031.5, Business and
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 that
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-m onop for in
ed prspection purposes.
M . SEE REVERSE FOR EXPLANATORY LANGUAGE
Signa a of Permittee �+/( Date