HomeMy Public PortalAbout10324 KEY WEST ST_Plumbing__ WGRKERS',COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I herelgy affirm that I havP a certificate of consent to self 76A667A
insure, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81)
ora certified co thereof (Sec. 3800, lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
'3tS —D�Dmpany TJ0A _ ,rusty-- G'
❑ Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING �r`
IL_ArJY Certified copy is filed with the county building inspec- ADDRESS
tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY
I TlDate tL g�—�� Applicant �- WATER CLOSET NEAREST p
CERTIFICATE OF EXEMPTION R M WORKERS' BATH TUB CROSS ST. ttK Af J ,
COMPENSATION IN ANCE OWNER
(This section need not be complete if the work involved by
SHOWER
the permit is for one hundred dollars $100 or less. g MAIL 1106 ��,`` ��,
P ( ) LAVATORY Y ADDRESS 010 /101MW
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner SINK 00 CITYrrA L TEL. NO.
so as to become subject to the Workers Compensation Laws. DISHWASHER 00 CONTRACTOR
Date Applicant CLOTHES WASHER ADDRESS ) V
NOTICE TO APPLICANT: If, after making this Certificate of 4 a /a 6
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY U TEL. NO l�l- a
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATERs_/1 LICENSE NO. CLASS C
LICENSED CONTRACTORS DECLARATION (J1) DISTRICT NO./, P OCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS J �r �l
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER (J
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL
DAT
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License Number 4/ Lic. Class_
Contractor Date p B
I amMpt under Sec. LWJ
B.BP.C. for this reason
Plan check fee
Date: PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE �®
SINGLE FAMILY s
Plan check applicant �2 7 Q 8 A
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's License Address # 0 0 0 0 0 5
Law for the following reason (Section 7031.5, Business and
Professions Code): City Tel. No. 1 - - 7650
❑ I, as owner,of the property, will do the work and the
structureis not intended or offered for sale (Section , 0 0 0 7(a 5 v
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY 0 a 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.
G��r SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signat of Permittee Date