HomeMy Public PortalAbout10312 KEY WEST ST_Plumbing__ t-
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)
-or ,certified copy thereof (Sec. 3800,'Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
e!�LZ_
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING �
Certified copy is filed with the county building inspec- ADDRESS
tion depaQprime t. NUMBER FIXTURE OR ITEM � FEE
LOCALITY
Date ' _0 n Applicantcid2k 9 WATER CLOSET v_ NEAREST
CERTIFICATE OF EXEMPTION R M WORKERS' I BATH TUB 0 CROSS ST. O A
COMPENSATION IN ANCE OWNER �'
SHOWER L U
(This section need not be complete if the work involved by 6 MAIL
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner ' SINK CITY ` TEL. NO. �'D
so as to become subject to the Workers Compensation Laws. DISHWASHER ___660 CONTRACTOR (— O'
I. /L
DateApplicant CLOTHES WASHER 6 ® V ADDRESS V
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR Exemption, you should become subject to the Workers'
StCompensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY D TEL. N b
with comply with such provisions or this permit shall be STATEB LIC.
deemed revoked. WATER HEATER LICENSE NO. (/V CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO. ROCESSED B
Q�
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER y
and Professions Code,and mmy/license is in full force and effect. 5 PER SYSTEM FFIANAL VA ATION
License Number SM, liLic. Class_
F I Ag
Contractor DateEl '
I an empt under Sec.
B.BP. for this reason
Plan check fee Pool
Date: PLUMBING PERMIT ISSUING FEE$ 16t S-0227 1.O A
Signature / ,�7•�
TOTAL FEE a Vim # a 0 0 0 0 5
Plan check applicant
SINGLE FAMILY ( ° - 76,50
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Address ° - 76505:
Law for the following reason (Section 7031.5, Business and
Professions Code): City Tel. No. Q $ 14-85
❑ 1, 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). 101
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_A_ddress
t
I certify hat I have read this application and state that the
above information is correct. I agree to comply with all County 011111.
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the
above-me ironed propert for inspection purposes.
O ���V_
1��r_ SEE REVERSE FOR EXPLANATORY LANGUAGE
Sign u e�oofA-Permittee (JD/ate