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Home My Public Portal About10303 KEY WEST ST_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT I hereby affirm that I have a certificate of consent to self insure, or.a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING or a certified copp{y,thhereof (Sec. 3800, Lggb. C.) 76A364C 4(S�S�s3Company- Certified p Y r �CE-818(REV. 10/81) PolicyNo. iZ.Com an' ❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING f� tion department. j /' . _ (PRINT OR TYPE ONLY) ADDRESS fi Date Applicant IFA+ At2 rok ,(D l ltolil PJJO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST i r� COMPENSATION INSURANCE CROSS ST. "J ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED B (This section need not be completed if the work involved by the permit is for one hundred dollars ($100,)or less.) AIR HANDLING UNIT, CFM I certify that in the perfZWork The' rk for which this permit is issued, I shall ny erson in any manner so as to become subjects''Compensation Laws. BOILER, BTU �( APPROVALS DATEPECT R'S SIGNATUREDate ACOMPRESSOR, BTU V v [i(/ ROUGH NOTICE TO APPLICANT: king this Certificate of VENTILATION SYSTEM FINAL Exemption, you shouldbject to the Workers' Compensation Pro"., s of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION with comply with ch provisions or this permit shall be deemed revoked. / FURNACE: FAU G TY LICENSED CONTRACTORS DECLARATION FLOOR BTU [/ D 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 3015319 Lic. Class C-ad S 0 t r GQY Date /C> Z 91� J Poo.Contrac o � F- ❑ I am exempt under Sec. V Plan check fee a H B.&P.C. for this reasonPERMIT ISSUING FEE $ ate: TOTAL FEE TV Signature OWNER-BUILD DECLARATION PLAN CHECK APPLICANT I hereby affirm that am empt from the Contractor's License Poo.Law for the following reason (Section 7031.5, Business and NAME -23266A Professions Code): ❑ 'I, as owner o/inteed rt or my employees with ADDRESS # ® o o a © 8 wages as their sation,will do the work and ° - 41L50 the structure isd or offered for sale(Section CITY TEL. NO.7044, Businesssions Code). OWNER 0 ,e ` aNc 4 4 5 0I, as owner of , am'exclusively contractingwith licensed to construct the project (Sec- MAIL tion 7044, Business and Professions Code). ADDRESS Q,2 4 -85 .CONSTRUCTION LENDING AGENCY CITY TEL. NO. I hereby affirm that there is a construction lending agency for 6 the performance of the work for which this permit is issued CONTRACTORPoo (Sec. 3097, Civ.'C.). ADDRESS - aC Lender's Name CITY TEL. NO. C' Lender's Address STATE LIC. r_;0 d I certify that I have read this application and state that the LICENSE NO. ® CLASS C� dC above information is correct. I agree to comply with all County ordinances and State laws relating to building construction, and hereby authorize representatives of.this County to enter upon the abAe-mentioned p perty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent to