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HomeMy Public PortalAbout10425 KEY WEST ST_Plumbing__ WORKERS'COMPENSATION DECLARATION A APPLICATION F®R PLUMBING P E R M I T I hereby affirm that I have a CE 81 certificate of consent to self 817 (;!-80) insure, or a certificate of Workers'Compensation Insurance,or �7— a ertified copy thereof(Sec. 3 00 Lab.C.) COUNTY OF LOS ANGELES / ' BUILDING AND SAFETY PI�.� Company Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING ADDRESS (,rV Certified copy is filed with the count bu'Idin 'ns ction NUMBER FIXTURE OR ITEM • FEE depart ent. WATER CLOSET LOCALITY Date �" t Applicant NEAREST BATH TUB 3 CROSS ST. jr CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE SHOWER d-O OWNER LAVATORYMAIL >_(This section need not be completed if the work involved ADDRESS �p S�i by the permit is for one hundred dollars ($100) or less.) SINK ev CITY T NO. 2 U I certify that in the performance of the work for which this DISHWASHER permit is issued, I shall not employ any person in any manner e rwJ�r�1 CONTRACTOR O so as to become subject to the Workers' Compensation Laws. CLOTHES WASHER V w ADDRESS Z 0 Date Applicant SWIMMING POOL RECEPTORLU CITY . NO s� y 0. NOTICE TO APPLICANT: If, after making this Certificate of TEL .5' 0 Exemption, you; should become subject to the Workers' LAWN SPRINKLER SYSTEM STATE © R LIC. Compensation provisions of the Labor Code, you must forth- CLASS with comply with such provisions or this permit shall be WATER HEATER deemed revoked. GAS SYSTEM OUTLETS DISTRICT NO. PRO SSED BY LICENSED CONTRACTORS DECLARATION OUTLETS OVER �� J • a 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 +�r VALIDATION ness and Professions Code, and my license is in full force and DATE CJ effect, c,� FINAL License NumbLia Clas BY rv{•- $"'"''J'"" Contractor—, Date I am exempta. the licensing requirements as I am a Plan check fee ©( licensed architect or a registered professional engineer PLUMBING PERMIT ISSUING FEE$ acting in my professional capacity (Section 7051, Bus- iness and Professions Code). TOTAL FEE Q� Lic.or Reg.No. Date Plan check applicant HOME OWNER-BUILDER DECLARATION Name rr I hereby affirm that I am exempt from the Contractor's Address z 4 9 97 A License Law for the following reason (Section.7031.5, Busi- City Tel. No. 0 0 0 0 0 ness and Professions Code): I, as owner of the property, am exclusively contracting 2 - . 4600 with licensed contractors to construct the project (Section 7044, Business and Professions Code). 0 0 0 A 6,0 0 c=i CONSTRUCTION LENDING AGENCY 04,28-81 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 repr ritatives of th' unty to enter upon th abo enti d operty fo p tion purposses.e ignature of Permittee Erate S' a