HomeMy Public PortalAbout10350 KEY WEST ST_Plumbing__ YVOrm,thi COMPENSATION DECLARATION APPLOCATIOlog FOR PLUMBING PERMIT
hereby toff+rm'thai I have a certificate of consent to self 76A667A
F"k,'.r'surel-or a c'ertificat'e of Workers' Compensation Insurance, CE 817(REV 10/81) 1, a
.or a,ceert'rfled cop thereof (Sec 3800, Lab C ) COUNTWOF LOS ANGELES BUILDING AND SAFETY
PO c oLOD �pao3ony;l+l ffP_ A6 11 D( 2&fl(/it-
❑ Certified copy is hereby furnished
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING'
Certified copy Is Med with the county building inspec- ADDRESS
tion department NUMBER FIXTURE OR ITEM ® FEE LOCALITY
J A I
Date ' Applicant WATER CLOSET (J�+ NEAREST
CERTIFICATE OF EXEMPTION M WORKERS' BATH TUB O CROSS ST
fWD
COMPENSATION IN ANCE I 00 OWNER J9
(This section need not be completed if the work involved by 61 SHOWER
the permit is for one hundred dollars $100 or less. MAID / n
P ( I LAVATORY Q ADDRESS �, .4, K
I certify that in the performance of the work for which this
permit Is Issued, I shall not employ any person in any manner ' SINK O 6 CITY ����Li f TEL NO
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so as to become subject to the Workers'Compensation Laws DISHWASHER �K•— /
a d CONTRACTOR
Date Applicant CLOTHES WASHER D
NOTICE TO APPLICANT If, after making this Certificate of ADDRESS
Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR
Compensation provisions of the Labor Code, you must forth- CITY y 19(/D TEL NO I
p p y LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC
deemed revoked WATER HEATER LICENSE NO �/1/ CLASS
jo LICENSED CONTRACTORS DECLARATION DISTRII T NQ PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS 10 06
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect 5 PER SYSTEM FINAL
2 DAT }
h V LIDATION �
License Number
59 7�r►p Lic Class 'Q(0 / V
`, �j FIN l 09
Contractor p y
Date O�� 'a r BY
❑ I am e, under Sec
B &P this reason , 2 7 1„1 A Z
-- Plan check fee
Date # — 0005
PLUMBING PERMIT ISSUING FEE$ ”
Signature TOTAL FEE S ,( - - 7650
Plan check applicant
SINGLE FAMILY - 76505
HOME OWNER-BUILDER DECLARATION Nome
I hereby affirm that I am exempt from the Contractor's License Address 0 8. 1 4"85
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
structure is not Intended or offered for sale (Section ,
7044, Business and Professions Code), 1
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 propert for Inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
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Sign a of Permit ee Date