HomeMy Public PortalAbout10420 KEY WEST ST_Plumbing__ WOIYKERS'COMPENSATION DECLARATION 76A887A
I-.hereby affirm that I have a certificate of consent to self ce 817 (z-80
) APPLICATION FOR PLUMBING PERMIT
insure, or a certificate of Workers''Compensation Insurance,or
a cerj2ed c�=�gp� 800,Lab C)
z0f,�L 3 4� COUNTY OF LOS ANGELES a BUILDING AND SAFETY,
Policy No Company Gd!
Certified copy is hereby furnished FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING D
ADDRESS
Certified copy is filed withthe co ty buildi in ection NUMBER FIXTURE OR ITEM FEE
de gnt WATER CLOSET ab LOCALITY
Date Applicant NEAREST
BATH TUB pb CROSS ST
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER
COMPENSATION INSURANCE ' SHOWER MAIL LAVATORY aA�.
(This section need not be completed if the work involved ADDRESS (; a0
by the permit is for one hundred dollars ($100) or less.) SINK tEL�'(� CITY TEL N 7 U
I certify that in the performance of the work for which this DISHWASHER / G . O
permit is issued, I shall not employ any person in any manner .� CONTRACTOR K/
so as to become subject to the Workers' Compensation Laws CLOTHES WASHER �/ v ADDRESS20�L U
Date Applicant SWIMMING POOL RECEPTOR L Ol
NOTICE TO APPLICANT If, after making this Certificate of CITY TEL NO�s 7 Z
Exemption, you should become subject to the Workers' LAWN SPRINKLER SYSTEM STATELIC
Compensation provisions of the Labor Code, you must forth- / LICENSE NO CLASS
with comply with such provisions or this permit shall be WATER HEATER
0-4
deemed revoked GAS SYSTEM OUTLETS 4-10 DISTRICT NO PR CESSED$Y
LICENSED CONTRACTORS DECLARATION OUTLETS OVER Jr
I hereby affirm that I am licensed under provisions of Chapter 15 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 ( (,j
effect /�
FIN
License Numb-
r v Lie Class — BY AL -�
Contractor Date
I am exempt from the licensing requirements as I am a Plan check fee (J
licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$
acting in my professional capacity (Section 7051, Bus- -
iness and Professions Code) I I 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
License Law for the following reason (Section 7031 5, Busi- City Tel No 2 5 0 0.7 A
ness and Professions Code)
I, as owner of the property, am exclusively contracting # o o o o o 5
with licensed contractors to construct the project
(Section 7044, Business and Professions Code) 2 o o 4 a.0 0
CONSTRUCTION LENDING AGENCY 0 0040,0006
1 hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is 04,28-81
issued(Sec 3097,Civ C)
Lender's Name
Lender's Address
I certify that I have read this application and state that the 4
above information is correct I agree to comply with all County SEE REVERSE FOR EXPLANATORY LANGUAGE
ordinances and State laws regulating Plumbing, and hereby
au th e r resentatives this County to enter upon the >
ab en i ne propert or inspection purposes
i
ignature of Permittee Date ,