HomeMy Public PortalAbout10342 KEY WEST ST_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
J hereby affirm that I have a certificate of consent to self 76A667A
ifture, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81)
a er ified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING ND SAFETY
Poii'*o(70�5o�'Ca�03 IDd�lly�j��'I1UAUd�'f, - '
❑ Certified copy is hereby furnished. G'
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspec-
tion department. NUMBER FIXTURE OR ITEM n FEE ADDRESS
(C/ -at—,
�� LOCALITY � LTV
Date- f �LD�Applicant WATER CLOSET VNEAREST
CERTIFICATE OF EXEMPTION F WORKERS' BATH TUB 6 Uv CROSS ST.
COMPENSATION INS R NCE , SHOWER OWNER J .
(This section need not be completed. the work involved by
the permit is for one hundred dollars($100)or less.) LAVATORY MAILJ414AJfld&7yAf Die
I certify that in the performance of the work for which this D� ADDRESS `
permit is issued, I shall not employ any person in any manner SINK CITY :5 r rTEL. NO,489�LZ�
so as to become subject to the Workers Compensation Laws. T1 DISHWASHER � CONTRACTORJ l7
Date Applicant CLOTHES WASHER ADDRESS.
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
CompLAWN SPRINKLER SYSTEM ensation provisions of the Labor Code, you must forth- CITY TEL. NO.��� D �qf®
with comply with such provisions or this permit shall be STATE a^�T B� LIC.
deemed revoked. WATER HEATER n LICENSE NO. /J V" CLASS
LICENSED CONTRACTORS DECLARATION 6 v� DISTRICT NO. ROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 ® GAS SYSTEM OUTLETS 6 t /)�
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER V >.
and Professions Code, and my license is in full force and effect. 5 PER SYSTEM FINAL VALI TION
License Number�-7 6�MD� Lic. Class d
FIN
Contractor Date '� ' B
❑ LM
I am mpi under Sec. LM
B.BP. . for this reason
Plan check fee g
Date: a
PLUMBING PERMIT ISSUING FEE$ .SCS 2 7 1.2 A
Signature
TOTAL FEE S
# 0 0 0 0 0 5
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name
Ia - 7650
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and Address o o o 7 6 5 0 5
Professions Code): City Tel. No.
❑ I, as owner of the property, will do the work and the $ 4 "85
structureis not intended or offered for sale (Section
7044, Business and Professions Code). plop
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-mentioned property for ins ection purposes.
�. SEE REVERSE FOR EXPLANATORY LANGUAGE
i Y11—9
SignatuaT
Permittee Date