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Home My Public Portal About10400 KEY WEST ST_Plumbing__ WORKERS'COMPENSATION DECLARATION 76A667A I'hereby affirm that I have a certificate of consent to self ce 817 (2-90) APPLICATION FOR PLUMBING P E R M'I T insure, or a certificate of Workers'Compensation Insurance,or _ -a certified copy thereof Sec 00,Lab Cf) , —2a L—O t�^OS (��(_// ` • COUNTY OF LOS ANGE LES �� BUILDING AND SAFETY( �� Policy No Com ny Certified copy is hereby furnished FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING � ADDRESS Certified copy is filed with-the count uildmg p tion ZdNUMBER FIXTURE OR ITEM FEE Z1 WATER CLOSET part erit '-/ LOCALITY Date, Applicant (/� _ �� NEAREST i BATH TUB CROSS ST CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE SHOWER �� 'OWNER' I• LAVATORY MAI L (This section need not be completed if'the work involved �"� ADDRESS O by the permit is for one hundred dollars ($100) or less.) SINK d v CITY TEL NoZ� U 10 I certify that in the performance of the work for which this / DISHWASHERCONTRACTOR OAU = • permit is issued, I,shall not employ any person in any manner • 0 -so as to become subject to the Workers' Compensation Laws CLOTHES WASHER t ADDRESS /L U LU Date Applicant SWIMMING POOL RECEPTOR CITY TEL NO .- �� tl NOTICE TO APPLICANT If, after making this Certificate of z Exemption, you should-become subject to the,Workers' LAWN SPRINKLER SYSTEM STATE / LIC ' Compensation provisions of'the Labor Code, you must forth- Q� LICENSE NO � i O CLASS with comply, with such provisions or this permit "shall be WATER HEATER deemed revoked DISTRICT NO ZESS9'D BY GAS SYSTEM OUTLETS (/ LICENSED CONTRACTORS DECLARATION OUTLETS OVER �, ( fib d I hereby affirm,that I am licensed under provisions of Chapter 5 PER SYSTEM 9 (commencing with Section 7000) of Division 3 of the Busi- FINAL VALIDATION ness and Professions Code, and my license is in full force and DATE effect _ FINAL f License Numb 27S vU Lie Class BY Contractor Date rI am exemptLm the licensing requirements as I am a Plan check fee licensed architect or a registered professional engineer /� } acting in, my professwnal capacity Section 7051, Bus- PLUMBING PERMIT ISSUING FEE$ ! mess and Professions Code) TOTAL FEE . orp 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 • 5 0 0 5 A License Law for the following reason,(Section 7031 5,, Busi- City Tel No " ness and Professions Code) # o o o o, o 5 I, as owner of the property, am exclusively contracting 2 0'0 (�Q Q 0 with licensed contractors to "construct the project , , (Section 7044, Business and Professions Code) y - 40005 � 40,005 CONSTRUCTION LENDING AGENCY 'I hereby affirm that there is a construction lending agency 0,A2 8-8 1 for the performance of the work for'which this permit is issued(Sec 3097,Civ C) Lender's Name Lender's Address y 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 aize re ntatives oft unty to enter upon the a v me on operty for sp coon purposes Signature of Permittee- date, _ WORKERS'COMPENSATION DECLARATION 76A667A 'A-P P L I C AT i O N FOR P L-,U M B,I N G PERMIT I hereby affirm that I have a certificate ,of consent to`.-elf 'CE ail (2-813) insure, or a certificate of Workers'Compensation Insurance,or - - p c d h o Se 800,Lab C) � l COUNTY OF LOS ANGELES BUILDING AND SAFETY . "'fro 0 any Certified copy is hereby furnished FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING ADDRESS rt copy is filed with the county mg inspection NUMBER FIXTURE OR ITEM • FEE e tm LOCALITY Date plicant' WATER CLOSET NEAREST BATH TUB CROSS ST CERTIFICATE,OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE SHOWER OWNER " MAIL (This section need not be completed if the work involved LAVATORYADDRESS o by the permit is"for one hundred dollars ($100) or less.) } SINK CITY 0 1 certify that in the performance of the work for which this DISHWASHER CONTRACTO U permit is issued, I shall not employ any person in any manner. cc so as to become subject-to the Workers"Compensation Laws CLOTHES WASHER ADORE 0 O Date Applicant SWIMMING POOL RECEPTOR CITY TEL NO 11J NOTICE TO APPLICANT If, after making this Certificate of you TEM ', d Exem tionshould become subject to the WorkersLAWN SPRINKLER SYS . P Y J STATE C/ / LIC W Compensation provisions of the Labor Code, you must forth- LICENSE NO O ty7� CLASS Z ' with comply with, such provisions or this permit shall be WATER HEATER deemed revokedT O E DISTRICT NO PR ESSED•BY LICENSED CONTRACTORS DECLARATION Z)O LE O I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM 9 (commencing with Section 7000) of Division 3 of the Busi- FINAL VALIDATION ness and Professions Code, and my license is in full force and DATE effect FINAL License Number Lic Class BY Contra Date I am exempt from the licensing requirements as I am a Plan check fee licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$ acting in my professional capacity (Section 7051, Bus- iness and Prs s Code TOTAL FEE Lic or Reg•No Date ) Plan check applicant Name HOME OWNER-BUILDER DECLARATION I hereby affirm that 'I ami exempt from the Contractor's Address License Law for the following reason (Section,7031 5, Busi- City Tel No' ness and Professions Code) - Jr 7 2.6 I, as owner of the property, am exclusively contracting 'A with licensed contractors to construct the project 0 0 65 (Section 7044,Business and Professions Code) 2 0 0"1 5'0 CONSTRUCTION LENDING AGENCY - - I hereby affirm that there is a construction lending agency o�0 io 6 5 0 v for the performance of the work for which this permit is', issued (Sec 3097,Civ C) Lender's Name a 1 r9=8 2 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 representatives of this County to enter upon the a ment oneddpr or inspection purposes Signature of Permittee Date