HomeMy Public PortalAbout10415 KEY WEST ST_Plumbing__ WORKERS'COMPENSATION DECLARATION 76A887A A P P'L I C A T I O N� FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self ce s» (z-so)
insure, or a certificate of Workers'Compensation Insurance,or
certified copy thereo_f�S,ec 3 o,Lab ) COUNTY OF LOS ANGELES, 7` e e . BUILDING AND SAFETY
Po icy No Compa y � � re `
Certified copy is hereby furnished FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING
ADDRESS 0
Certified copy is filed withgthe;ou/ybml n ns coon NUMBER FIXTURE OR ITEM ® FEE
Datedepar m t LOCALITY
Applicant WATER CLOSET NEAREST /.
-
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST
COMPENSATION INSURANCE / SHOWER , >D OWNER ;
c
(This section need not be completed if the work involved LAVATORY MAIL 3 d� ADDRESS }
by the permit is for one hundred dollars ($100) or less.) SINK
CITY TEL NO * 0
I certify that in the performance of the work for which this ' DISHWASHER / V
permit is issued, I shall not employ any person,in any manner CONTRACTOR 4f/
so as to become subject to the Workers' Compensation Laws CLOTHES WASHER ADDRESS�J ` v O
Date y Applicant SWIMMING POOL RECEPTOR �i ~
NOTICE TO APPLICANT If, after making this Certificate of CITYz6 cf TEL NO W
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM LIC (�
Compensation provisions of the-Labor Code, you must forth- STATE LICENSE NO - 1/ '' CLASS U)
with comply with such provisions or this permit shall be WATER HEATER
deemed revoked GAS SYSTEM OUTLETS DISTRICT NO PRO ESSED Y
LICENSED CONTRACTORS DECLARATION OUTLETS OVER 6 v
I hereby affirm that I am licensed under provisions of Chapter 5 PER SYSTEM
9 (commencing with Section 7000) of Division 3 of the Busi- FINAL
ness and Professions Code, and my license is in full force and DATE VALIDATION r' r
effect
75?�y
FINAL
License Number, d40 Lie Class � �i BY
Contractor Date 1T/('J —if-I
F1I am exem rom the licensing requirements as I am a Plan check fee / GV
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code) TOTAL FEE
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 4 9 9, 8 A
License Law for the following reason (Section 7031 5, Busi- City Tel No
ness and Professions Code) # 0 0 0 o 0 5r
I, as owner of the property, am exclusively contracting 2 0 0 4
with licensed contractors to construct the project
600
(Section 7044, Business and Professions Code) o o o 4 6,0 0 2:
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-
authorize re p�,vesyof th County to enter upon the
ab e- en o ertfor a County
purposes
iii.JA
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Signature of Permittee Date