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Home My Public Portal About10405 KEY WEST ST_Plumbing__ WORKERS'COMPENSATION DECLARATION 78A8e7A ) APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a certificate of consent to self CE e» (z-ao insure, or a certificate of Workers'Compensation Insurance,or certified co y theiggf 1pany 3800,Lath C) \, L�� ft/ COUNTY OF LOS ANGELES T� BUILDING AND SAFETYPolicy No Co - Certified copy is hereby furnished FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING- ADDRESS ADDRESS 1W Certified copy is filed with the county builds i pection NUMBER FIXTURE OR ITEM • FEE LOCALITY deparLment / WATER CLOSET Date Applicant " NEAREST ` BATH TUB � CROSS ST CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER COMPENSATION INSURANCE SHOWER ow LAVATORY MAIL gzyc >_(This section need not be completed if the work involved Gita ADDRESS by the permit is for one hundred dollars ($100) or less.) SINK CITY T NO U I certify that in the performance�'of the work for which this DISHWASHER �� CONTRACTOR permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws CLOTHES,WASHER `V `ADDRESS W Date Applicant SWIMMING POOL RECEPTOR CITY O �, fa NOTICE TO APPLICANT If, after making this CeTEL N rtificate of ' Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE LIC Z Compensation provisions of the Labor Code, you must forth- LICENSE NO �� CLASS with comply with such provisions or this permit shall be r WATER HEATER 'ji ow. deemed revokedDISTRICT NO PRO SSE f3 Y GAS SYSTEM OUTLETS LICENSED CONTRACTORS DECLARATION OUTLETS OVER I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM 9 (commencing with Section 7000) of Division 3 of the Busi- FINAL VALIDATION ness and Professions Code, and my license t!� " is in full force and DATE � effect FINAL r+ License Numbe Lic Class v BY Contractor Date '" tJ • I am exempt from the licensing requirements a I am a Plan check fee licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$ �Q acting in my professional capacity (Section 7051, Bus- iness and Professions Code) TOTAL FEE 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 ness and Professions Code) :2 4 9 9,9 A I, as owner of the property, am exclusively contracting with licensed contractors to construct the project # 0 0 o 0 0'5 (Section 7044, Business and Professions Code) CONSTRUCTION LENDING AGENCY 2 0`0 [) Q Q I hereby affirm'that there is a construction lending agency b 0 0 4 6 0 Q X for the performance of the work for which this permit is issued(Sec 3097,Civ C) 0 4 2 8-8 1 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 authorise r resentatives o is County to enter upon the me d property i spection purposes Signature of ermittee Date WORKERS'COMPENSATION DECLARATION 76A667A I hereby affirm that I have a certificate of consent to self CE 817 (2-60) 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 BUILDING AND SAFETY Policy No Company Certified copy is hereby furnished FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING G Certified copy is filed with the county building inspection NUMBER FIXTURE OR ITEM FEE ADDRESS LOCALIT �O /e Cw /790 department WATER CLOSET Date Applicant NEAREST BATH TUB CROSS ST A 7r7 CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE SHOWER OWNER,- CJ MAIL (This section need not be completed if the work involved LAVATORY ADDRESS d by the permit is for one hundred dollars ($100) or less.) SINK 0 CITY TEL NO 0 I certify that in the performance of the work for which this DISHWASHER �� O permit is issued, I shall not employ any person in any manner CONTRACTOR so as to become subject to the Workers' Compensation Laws CLOTHES WASHERADDRESS F- Date ApplicanttL SWIMMING POOL RECEPTOR NOTICE TO APPLICANT If, after making this Certificate of CITY TEL NO a rn Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE LIC Z Compensation provisions of the Labor`Code, you must forth- LICENSE NO CLASS with comply with such provisions or this permit shall be WATER HEATER r deemed revoked GAS SYSTEM QJ)OUTLETS DISTRICT NO PROCESSED BY LICENSED CONTRACTORS DECLARATION OUTLETS OVER ii5i I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM 9 (commencing with Section 7000) of Division 3 of the Busi- FINAL VALIDATION ness and Professions Code, and my license is in full force and- DATE 2 �� ` Z effect FINAL License Number Lrc Class BY Contractor Date I am exempt from the licensing requirements as I am a Plan check fee licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$ acting in my professional capacity (Section 7051, Bus- iness and Professions Code) TOTAL FEE c, 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 ness and Professions Code) I, as owner of the property,,am exclusively contracting with licensed contractors to construct the project 2 2 7 3 8 A (Section 7044, Business and Professions Code) #'° ° ° ° 05 CONSTRUCTION LENDING AGENCY Z ° ° 1250 I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is 0N0 0 1 25070- issued(Sec 3097,Civ C) Lender's Name 0 -1.261-82 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 Pis County tenter upon the n above-meconed propert inspe tion poses ig ' re of erI to Date