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Home My Public Portal About10370 KEY WEST ST_Plumbing__ WORKERS'COMPENSATION DECLARATION 76A667A "I hepebi� affirm that I have a certificate of consent to self ce 617 (z-60) APPLICATION FOR PLUMBING PERMIT -insure, or a certificate of Workers'Compensation Insurance,or a.certified copy thereof Sec. 3800,Lab.C.) COUNTY OF LOS ANGELES T`�� BUILDING AND SAFETY thereof Sec. Policy No. CompanyPoor Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING Certified co is filed with the county NUMBER FIXTURE OR ITEM • FEE ADDRESS f� 76 1.2&., L(/ copy y buildi n ection LOCALITY �^ el part ent. Z WATER CLOSET Dat .— 'Z� Applicant �" NEAREST i BATH TUB �0 CROSS ST. CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE SHOWER OWNER LAVATORY �ADDRE AIL (This section need not be completed if the work involved Z o-v SS Oby the permit is for one hundred dollars ($100) or less.) SINK <v TY TE 4:/N OZZ U I certify that in the performance of the work for which this DISHWASHER permit is issued, I shall not employ any person in any manner CONTRACTOR Idly so as to become subject to the Workers' Compensation Laws. CLOTHES WASHER ADDRESS DateApplicant SWIMMING POOL RECEPTOR 01 d NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL. NO�' a. Cn Exemption, you should become subject to 'the Workers' LAWN SPRINKLER SYSTEM STATE LIC. Z Compensation provisions of the Labor Code, you must forth- LICENSE NO. 779 7 . CLASS C with comply with such provisions or this permit shall be WATER HEATER G� deemed revoked. GAS SYSTEM OUTLETS �V DISTRICT NO. PR CES SED Y LICENSED CONTRACTORS DECLARATION OUTLETS OVER siVO I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM 9 (commencing with Section 7000) of Division 3 of the Busi- FINAL ness and Professions Code, and my license is in full force and DATE G� �— VALIDATION �� effect. FINAL License Numb e " v Lie.Class BY Contractor Date — "Olt ElI am exempt from the licensing requirements as I am a Plan check fee / licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$ acting in my professional capacity (Section 7051, Bus- iness and Professions Code). ITOTAL FEE Lie.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 followingreason Section 7031.5, Busi- G` �'3 ( City Tel.No. ness and Professions Code): # o o o o 0-5 ElI, as owner of the property, am exclusively contracting with licensed contractors to construct the project 2 0 - 4000 (Section 7044, Business and Professions Code). 40,00 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency 0 [I, 2 8-81 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 SEE REVERSE FOR EXPLANATORY LANGUAGE ordinances and State laws regulating Plumbing, and hereby authorizer presentatives of is County to enter upon the ve a one pro�pert/y nspection purposes. Lt/ Signature of Permittee I Date WORKERS'COMPENSATION DECLARATION 76A667A I hereby affirm that I have a certificate of consent to self CE 617 (z-60) APPLICATION FOR PLUMBING U M B I N G PERMIT insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800, b.C.) d.Z735 COUNTY OF LOS ANGELES - BUILDING AND SAFETY P icy No. Company Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING ADDRESS rtifie c filed with he coun din i pection NUMBER FIXTURE OR ITEM • FEE LOCALITY Datecant. S —WATER CLOSET NEAREST / BATH TUB CROSS ST. CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE SHOWER OWNER LAVATORY MAIL } (This section need not be completed if the work involved ADDRESS Oa by the permit is for one hundred dollars ($100) or less.) SINK CITY T O. U I certify that in the performance of the work for which this DISHWASHERcr_ permit is issued, I shall not employ any person in any manner _CONTRACTOR : 0 so as to become subject to the Workers' Compensation Laws. CLOTHES WASHER ADDRESS U Date Applicant SWIMMING POOL RECEPTOR d NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL. to Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE LIC. v Compensation provisions of the Labor Code, you must forth- LICENSE NO. CLASS with comply with such provisions or this permit shall be WATER HEATER deemed revoked. GAS SYSTEM OUTLETS DISTRICT NO. PRO ESSED BY Y LICENSED CONTRACTORS DECLARATION OUTLETS OVER I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM 9 (commencing with Section 7000) of Division 3 of the Busi- FINAL r� VALIDATION ness and Professions Code, and my license is in full force and DATE -a Q effect. FINAL License mber C.Cl s BY T o Dat_1 EMS m exempt from the licensing requirements as I am a Plan check fee nsed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$ ing in my professional capacity (Section 7051, Bus- ss and dei TOTAL FEE sd Lic.or Reg.No. O)L._ Date Plan check pIA..II HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's Address reason Section.7031.5, Busi- 235 1, 1 A License Law for the following ( City Tel.No. ness and Professions Code): ,E o o o o o 5 I, as owner of the property, am exclusively contracting with licensed contractors to construct the project 2 0 o 1 650 (Section 7044, Business and Professions Code). 1 650� CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency O U,0 5—8 2 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 SEE REVERSE FOR EXPLANATORY LANGUAGE ordinances and State laws regulating Plumbing, and hereby thoriz- representatives of this County to enter upon the b e- re resent pro er for inspection purpos ignature of Permitte Date