HomeMy Public PortalAbout10300 KEY WEST ST_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby^affirm that I have a certificate of consent to self
insure, ora 7certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec..3800, Lab. Q.) 76A364C
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acy No. D:.] .+ Company � p'�`�IV
Certified copy is hereby furnished. COUNTY OF LOS ANGELES' BUILDING AND SAFETY
nj/Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
ADDRESS o-500 (�e �5
'1 tion department. ', z (PRINT OR TYPE ONLY)
Date Applicant JZ AirGVt IoA++ LOCALITY C
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST. t
B
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED
the permit is for one hundred dollars (5100)or less.) �( �)�
I certify that in the performance the work for which this AIR HANDLING UNIT, CFM (f
permit is issued, I shall not em y any person in any manner BOILER, BTU
so as to become subject to a Workers'Compensation Laws. f1 APPROVALS DATE INSP CTOR'S SIGNAT RE
COMPRESSOR, BTU 0D ROUGH
Date Applicant
NOTICE TO APP ANT: If, after making this Certificate of VENTILATION SYSTEM FINAL _
Exemption, y u should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VAI IDATI N
with comply with such provisions or this permit shall be
deemed revoked. If FURNACE: FAU v GRAyITY ,r y�n
LICENSED CONTRACTORS DECLARATION FLOOR BTU C'r u Od
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
'(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code,and my license is in full force and
' effect.
License Number 3 bS 3 t5 l
Lic. Class c-0-to U
� 5�.. 1 d u•c. 0 l�
Contractor EJ Sltehe- -f Date
I am exempt under Sec.
P an check fee
B.&P.C. for this reason
Date:
PERMIT ISSUING FEE $
Signature TOTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT.
I hereby affirm that I am exem t om the Contractor's License ,
Law for the following reoor, ection 7031.5, Business and NAME a'3260A
s
Professions Code):
❑ I, as owner of the pr perty, or my employees with
ADDRESS # 0 0 0 0 0 8
wages as their sole c pensation,will do the work and CITY TEL. NO. o.0 4 LL 5 0
the structure is not i ended or offered for sale(Section
7044, Business an rofessions Code). '
OWNER � ® o a 4/l.5'0
❑ I, as owner of th property, am exclusively contracting
with licensed ntractors to construct the project (Sec- MAIL
tion 7044, Bu ness and Professions Code). ADDRESS ( 0,2 4-8 5
CONSTRUCTION LENDING AGENCY CITY TEL. NO. �'6-'�63
I hereby affirm that there is a construction lending agency for ,
the performance of the work for which this permit is,issued CONTRACTORt
(Sec. 3097, Civ. C.). S
ADDRESS
Lender's Name
CITY TEL. NO. q6q- '
Lender's Address
STATE LIC. ^��
I certify that I have read this application and state that the LICENSE NO. Q 3 CLASS (i
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize repres ntotIves
of this County to enter
upon the ove-mentioned operty for inspection purposes. ' SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date