HomeMy Public PortalAbout9828 KEY WEST ST_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby, affirm that I have a certificate of consent to self in 76A6667A WJ 490
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sure,or cicertificble of Workers'Compensation Insurance,or a
certified copy thereof (Sec 3800, Lab C )
COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORK
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Policy No Company
Certified copy is hereby furnished
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspection ADDRESS
department NUMBER FIXTURE OR ITEM @ FEE LOCALITY
Ddte Applicant WATER CLOSET(TOILET) NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST
COMPENSATION INSURANCE SHOWER OWNER 1,-;;?e
(This section need not be completed if the work involved by MAIL
the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS
I certify that in the performance of the work for which this per-
m
er- SINK
mit is issued, I shall not employ any person in any manner so CITYTEL NO.,
as to become subject to the Workers'Com ensation Laws DISHWASHER
CONTRACTOR
Date BJ-9—Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT if, after making this Certificate of Ex- SWIMMING POOL RECEPTOR '/�I.' A
emption,you should become subject to the Workers'Compen- CITY TEL NO�y3(A7(o
sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEMS
ly with such provisions or this permit shall be deemed revok- STATE LIC A,tj
ed , WATER HEATER LICENSE NO (u�3�o CLASS
LICENSED CONTRACTORS DECLARATION DISTRICT NO PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS ��•
9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code, and,my license is in full force and ef- 5 PER SYSTEM FINAL VALIDATION
fect 619,6149-1
QQ HOSE BIB DATE %l�"
License Number 1v83�0 Lic Class
MM FIANAL V
Contractor -� Date fZJ-�� BI am exempt under SecB&P C for this reason Plan check fee ► yDate PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Plan check applicant _
I hereby affirm that I am exempt from the Contractor's License Name ,_` n s
Law for the following reason (Section 7031 5, Business and
Professions Code) Address
1, as owner of the property, will do the work and the City Tel No
structure is not intended or offered for sale(Section 7044,
Business and Professions Code) TI_i 7AL 4 1 'E.32*5
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for =))hf (s� --
the performance of the work for which this permit is issued
(Sec 3097, Civ C )
Lender's Name
Lender's Address - may I r-, i
I certify that I have read this application and state that the
above information is correct I agree to comply with all County
ordinances and State laws regulating Plumbing, and hereby
authorize representatives of this County to enter upon the t
above-mentioned property for inspection purposes,
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date