HomeMy Public PortalAbout10319 KEY WEST ST_Plumbing__ .WORKERS'' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I herelby affirm-that I have a certificate of consent to self 76A667A
insure, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81)
ct? ti ied copy thereof (Sec. 3800.,ILab. C. COUNTY OF LOS ANGELES BUILDING AND SAFETY
c4tNb0205A^ ompany N �/�/1t�j��i IiwL(v`�
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING �/
Certified copy is filed with the county building inspec- ADDRESS K61 to
tion department. NUMBER FIXTURE OR ITEM Q FEE
j(Cr LOCALITY �'mPLr
Date -V a Applicant 21 WATER CLOSET NEAREST
CERTIFICATE OF EXE MPTIO ROM WORKERS' BATH TUB d� CROSS ST. I�DIi
COMPENSATION I URANCE OWNER � V �,
(This section need not be completed if the work involved by 1 SHOWER �'�
the permit is for one hundred dollars ($100)or less.) LAVATORY MAIL /�
�� ADDRESS � Ay �-e
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK CITY gAd G n/7 �` TEL. NO.
so as to become subject to the Workers Compensation Laws. DISHWASHER ClY ,b�
CONTRACTOR
Date Applicant CLOTHES WASHER O� ADDRESS �!
NOTICE TO APPLICANT: If, after making this Certificate of :
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY O � � TEL. NO. _q
with comply with such provisions or this permit shall be LAWN SPRINKLER SYSTEM STATE LIC.
deemed revoked. WATER HEATER ®O LICENSE NO. 19X1I0� CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT No. P CESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS /g
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER `(� Left
and Professions Code, and my license is in full force and effect. 5 PER SYSTEM FINAL
DAr — VALI ATION
License Number'S /b�{ C-3 00 Lic. Class _ G� U
Fl
Contractor fAl Date ,lq—ttC B
❑ 16"I am pt under Sec. 9-
B.&P.C. for this reason
Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE �®
SINGLE FAMILY Plan check applicant
2-7 O.7 A
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Address # o o o o o 5
Law for the following reason (Section 7031.5, Business and
Professions Code): City Tel. No. I o o 7 6 5 O
❑ I, as owner of the property, will do the work and the
structureis not intended or offered for sale (Section ® o o a 7 &5 O v
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY 08. 1 4-85
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.).
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 property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
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Sig t re of Permittee Date