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Home My Public Portal About10307 KEY WEST ST_Plumbing__ APPLICATION FOR PLUMBING PERMIT '• WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self 20-0026 DPW 6/87 insure, or a certificate of Workers' Compensation Insurance, 76A667A or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy No. Company ❑ Certified copy is hereby furnished. 17FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING D D Certified copy is filed with the county building inspec- ADDRESS 3 a✓ 14� W&S 1T S T tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date Applicant WATER CLOSET 6--� �0�� NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE SHOWER OWNER I_ZAJ, Cf- uAJ cHL4AJ (This section need not be completed if the work involved by MAIL _ the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS, 1030-7 <<� 'ST S I certify that in the performance of the work for which thist'�/ •3�_ permit is issued, I shall not employ any person in any manner SINK CITY jir� /& Cil TEL. NO.0 CLS so as to become subject to the Workers'Compensation Laws. DISHWASHER Q CONTRACTOR Date _ _ O Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certif ate of Exemption, you should become 'subject to the Workers' SWIMMING POOL RECEPTOR CITY TEL. NO. Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be ✓ STATE LIC. deemed revoked. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. CESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDATIO 0.1 License Number Lic. Class DATE 0. U. FINA Contractor Date BY ❑ Q� I am exempt under Sec. B.BP.C. for this reason @� Plan check fee Date: PLUMBING PERMIT ISSUING FEE$ m• Signature t TOTAL FEE Plan check applicant SINGLE FAMILY `7'drf7 nV1 HOME OWNER-BUILDER DECLARATION Name 3307 I hereby affirm that I am exempt from the Contractor's License Address Low for the following reason (Section 7031.5, Business and 3307 r Professions Code): City Tel. No. Ciro:tQ I, as owner of the property, will do the work and the S %TENS structure is not intended or offered for sale (Section ® TOTAL 7044, Business and Professions Code). 16-52 2 CONSTRUCTION LENDING AGENCY 16051, 1 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.). cv Lender's Name ,?"t Lender's Address � - 1 7/17/89' 1 certify that I have read this application and state that the ® JLJ1 1 �� above information is correct. I agree to comply with all County J0 SO-'17 ordinances and State laws regulating Plumbing, and hereby - authorize 7-/2—R representatives of this County to enter upon the abov -rnentione property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee# DateJ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby•affirm that I have a certificate of consent to self 76A667A ;r ,ure, ora certificate of Workers' Compensation Insurance, CE 817(REV. 10/81) or',n certifi d co y thereof Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY a50 icy.No. Company tti-1( f' Certified copy is hereby furnished. � / U�� ® FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy is filed with the county building inspec- ADDRESS tion depart nt. NUMBER FIXTURE OR ITEM @ FEE LOCALITY i �� WATER CLOSET1 00 Date ApplicantCOVIL_ NEAREST n CERTIFICATE OF EXEMPTIO ROM WORKERS' BATH TUB CROSS ST. V COMPENSATION I RANCE SHOWER ,�^ OWNER (This section need not be comple ed if the work involved by VV MAIL (Qp �,` ,y��/ g fplg the permit is for one hundred dollars ($100)or less.) LAVATORY UO ADDRESS &5' 1&Jr1 J&J4f big I certify that in the performance of the work for which this �^ ��, L919�� _�� permit is issued, I shall not employ any person in any manner SINK CITY Ll TEL. NO. so as to become subject to the Workers Compensation Laws. 4 DISHWASHER to oo CONTRACTOR 11 d. (° Date Applicant CLOTHES WASHER ( bb/,)^^'' d� NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS /./- U2. f_2�416MAM� C Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY/°' 044 719 D TEL. NO. �( D�` with comply with such provisions or this permit shall be STATED LIC. uV/s deemed revoked. WATER HEATER x.11 LICENSE NO. CLASS C-S LICENSED CONTRACTORS DECLARATION DISTRICT N PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS to 00 (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINALV LIDATION`; C) l CMI License Number � Lic. Class DATE V Q }� FINAL Contractotempt Date ++/ �v BY 2 7 1, 8 A ❑ I amunder Sec. # o00005 Bis reason , ) o - 94,50 g Date: Plan check fee PLUMBING PERMIT ISSUING FEE$ 10 Signature o - 94.5050 TOTAL FEE01 Plan check applicant 0 8 4_85 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 Professions Code): City Tel. No. ❑ I, as owner of the property, will do the work and the o 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-m ioneclpropert for inspection purposes. y'/�'�� SEE REVERSE FOR EXPLANATORY LANGUAGE Sign re of Permittee Date