HomeMy Public PortalAbout10410 KEY WEST ST_Plumbing__ X70 KERS'COMPENSATION DECLARATION 76A667A
I hereby affirm that I have a certificate of consent to self CE 1117 (z-so) APPLICATION FOR PLUMBING PERMIT
insure, or a certificate of Workers'Compensation Insurance,or '7'
a c�Py�'tified copy thereof(Sec 3800,Lab ) COUNTY OF LOS ANGELES
1 BUILDING AND SAFETY
Policy No Company
Certified copy is hereby furnished FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING 0
ADDRESS
Certified copy is filed with the cougty buildinoff7ection NUMBER FIXTURE OR ITEM FEE
Dat;2partl LOCALITY
Applicant WATER CLOSET NEAREST
i
BATHTUB �/(, CROSS ST i
CERTIFICATE OF EXEMPTION FROM WORKERS' L�
COMPENSATION INSURANCE SHOWEROWNER
LAVATORY MAIL /
(This section need not be completed if the work involved �� ADDRESS �P }
by the permit is for one hundred dollars ($100) or less.)
SINK
(�'� CITY TE O o-
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1 certify that in the performance of the work for which this DISHWASHER U
permit is issued, I shall not employ any person in any manner CONTRACTOR
so as to become subject to the Workers' Compensation Laws CLOTHES WASHER 3 ADDRESS 0
Date Applicant SWIMMING POOL RECEPTOR CITY TEL NOS + Uj
NOTICE TO APPLICANT If, after making this Certificate of CUj
L
Exemption, you should become subject to the Workers' LAWN SPRINKLER�SYSTEM STATE LIC
p 1
Compensation provisions of the Labor Code, you must forth- WATER HEATER �� LICENSE NO CLASS Z
with comply with such provisions or this permit shall be
deemed revoked GAS SYSTEM OUTLETS DISTRICT NO PROC SSED B
LICENSED CONTRACTORS DECLARATION OUTLETS OVER � o
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM /
9 (commencing with Section 7000) of Division 3 of the Busi- FINAL
DATE �/ �� — VALIDATION
nes Pro ions Code, and my license is in full force and
eff t (rU1
FINAL
License Numbe Lic Class BY
Contractor Date �l
0 1 am exempt from the licensing requirements as I am a Plan check fee
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$ V v
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 ;?5 0 Q 6 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 4-600
with licensed contractors to construct the project
(Section 7044, Business and Professions Code) _
046,00�
CONSTRUCTION LENDING AGENCY 0 4 2 8_8 1
I hereby affirm that there is a construction lending agency
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
oounty to enter upon the
orposesr•
ignature of Permittee fDate