HomeMy Public PortalAbout10380 KEY WEST ST_Plumbing__ WORKERS'COMPENSATION DECLARATION 76A667A
I Hereby affirm that I have a' certificate of consent to self CE fin (z-ao) APPLICATION FOR PLUMBING PERMIT
insure, or a certificate of Workers'Compensation Insurance,or /)
a certified copy thereof(Sec. 3800,Lab.�.)
COUNTY OF LOS.ANGELES BUILDING AND SAFETY_
Policy No. Company 4Q/Ay
Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING O
ADDRESS
Certified copy is filed with the count buildin ction NUMBER FIXTURE OR ITEM • FEE
Datedepart ent. . / LOCALITY
_ Applicant W Z WATER CLOSET �b NEAREST r
BATH TUB �p-� CROSS ST. L
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE SHOWER �v OWN `
LAVATORY // MAIL
(This section need not be completed if the work involved to i�7 ADORES
by the permit is for one hundred dollars ($100) or less.) �p
SINK CITY TEL. O. 7a.
I certify that in the performance of the work for which this DISHWASHERV
permit is issued, I shall not employ any person in any manner �ryCONTRACTOR
so as to become subject to the Workers' Compensation Laws. CLOTHES WASHER /
ADDRESS 2z
Date Applicant SWIMMING POOL RECEPTOR (�
NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL. NOS7J
Exemption, ' LAWN SPRINKLER SYSTEM
J STATE q LIC. 0.you should become subject to the Workers
Compensation provisions of the Labor Code, you must forth- �� LICENSE N
WATER HEATER O. �S ! Q CLASS z
with comply with such provisions or this permit shall be e
deemed revoked. GAS SYSTEM OUTLETS DIST/—RICT�NO. PRO SSED BY
LICENSED CONTRACTORS DECLARATION OUTLETS OVER �7 lot
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000) of Division 3 of the Busi- FINAL /� ® '` � VALIDATION
ness and Professions Code, and my license is in full force and DATE 8f� -�-" i./
effect.
LicenseNumb Lia Class � FINAL lV 0
BY
v
Contractor Date
I am exempt fr m the licensing requirements as I am a Plan check fee 1
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). TOTAL FEE 0
Lic.or Reg.No. Date Plan check applicant
HOME OWNER-BUILDER DECLARATION Name
Address
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section.7031.5, Busi- City Tel.No.
ness and Professions Code): ;25004A
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project 4 0 0 0 0 0 5
(Section 7044, Business and Professions Code).
2 - - 40,00
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency o 40,005)
for the performance of the work for which this permit is
issued(Sec. 3097,civ.C.). 0 4,28-81
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 re ulating Plumbing, and hereby
authorizepresentatives o t is County to enter upon the
me o d propert r' spection purposes.
Signature of Permittee fbate