HomeMy Public PortalAbout10360 KEY WEST ST_Plumbing__ WORKERS'COMPENSATION DECLARATION 76A667AC ,
I hereby affirm that I have a certificate of consent to self CE en (z-6o) 'APPLICATION FOR PLUMBING PERMIT 7U'
insure, or a certificate of Workers'Compensation Insurance,or .
a certified co y thereof(Sec. 3800,Lab.C.)
,p�Z,- a�-CS/f y? ,_ / , � : COUNTY OF LOS ANGELES 7—, BUILDING AND SAFETY_,
' Policy No Company—
Certified
ompany Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING Q 6fl
ADDRESS
Certified copy is filed with the coun bull d� ins ection NUMBER FIXTURE OR ITEM • FEE
depart e t �.1••� LOCALITY
Datezt. Applicant WATER CLOSET V v NEAREST /
BATH TUB CROSS ST
CERTIFICATE OF EXEMPTION FROM WORKERS' ,
COMPENSATION INSURANCE SHOWER P,� OWNERS
LAVATORY MAIL
(This section need not be completed if the work involved ADDRESS }
by the permit is for one hundred dollars ($100) or less.) SINK
�� CITY L N 0
I certify that in the performance of the work for which this DISHWASHER 3 / V
permit is issued, I shall not employ any person in any manner CONTRACTOR W
so as to become subject to the Workers' Compensation Laws CLOTHES WASHER
ADDRESS Z„e�' O
Date Applicant SWIMMING POOL RECEPTOR �v�—II U
NOTICE TO APPLICANT• If, after makmg'this Certificate of CITY TEL. NO s.. 03
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATELIC to
Compensation provisions of the Labor Code, you must forth- 3. �0 LICENSE NO Q (? CLASS G Z_
with comply with such provisions or this permit shall be WATER HEATER
deemed revoked GAS SYSTEM OUTLETS DISTRICT NO PRO ESSED Y
LICENSED CONTRACTORS DECLARATION OUTLETS OVER �/ �d
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000) of Division 3 of the Buse- FINAL / ����� VALIDATION
ness and Professions Code, and my license is in full force and DATE
effect.
J I T FINAL /�
License Numb d d V Lic Class BY 1—�--.---
Contractor Date 49L 1f=4
(o/ Q /
I am exempt frol the licensing requirements as I am a Plan check fee
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$
acting to my professional capacity'(Section 7051,-Bus-
iness and Professions Code). , TOTAL FEE +6 6�
Lic or Reg.No Date Plan check applicant
HOME OWNER-BUILDER DECLARATION Name
I hereby affirm that I am exempt from the Contractor's Address
License Law for the following reason (Section ,7031 5, Busi- City Tel No 2 5 0 0 2 A
ness and Professions Code)
I, as owner of the property, am exclusively contracting # 0 0 0 0 0 5
with licensed contractors to construct the project
(Section 7044, Business and Professions Code) 2 o,-.46,00
CONSTRUCTION LENDING AGENCY ° ° °,4-6,0 0'ca”
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit Is 0 4,2 8-,8 1
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 SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances and State laws regulating Plumbing, and hereby
authorize r pres tatrves of t County to enter upon the
ove- a on erty fo s ection purposes
Signature of Permittee Date