HomeMy Public PortalAbout10306 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 copy thereof (Sec. 3800,t �Lab. C.) 76A364C
3Z ctCE-818(REV. 10/81)
Policy No. Company J
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING A D SAFETY
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. Al" /1 (PRINT OR TYPE ONLY) ADDRESS
Date Applicant (�� \ 90A4 LOCALITY I e ��, '
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE 1
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY
the permit is for one hundred dollars ($100)or less.)
AIR HANDLING UNIT, CFM Gr'
I certify that /no
rformance. the work for which this
permit is issunofempl any person in any manner
so as to becot to the orkers'-Compensation Laws. BOILER, BTU APPROVALS DATE INS +OR'S SIGNATURE
Date p cant COMPRESSOR, BTU UUD ROUGH
NOTICE TO A • f, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, yd become subject to the Workers'
Compensatios of the Labor Code, you.must forth- EVAPORATIVE COOLER VALIDATION
with comply provisions or this permit shall be
deemed revo FURNACE: FAU GR VITY /y
LICENSED CONTRACTORS DECLARATION FLOOR BTU lI1 6
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 Number305 3 l9 Lic. Class C-eLO O
dtZr
Contractor EA S Date 16 liq/g7 ,f U
❑ I am exempt under Sec. U LU
Plan check fee
B.&P.C. for this reaso H
PERMIT ISSUING FEE $ S0 Z
Date:
TOTAL FEE
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT :2 3 2 6 1 A
I hereby affirm that I am exempt from the Contractor's License
Low for the followin/ended
e on 7031.5, Business and NAME , # o.0 0 0 0 8
Professions Code):
❑ I, as owner orty, or my employees with ADDRESS .1 o o 44,5 0
wages as their nsation,will do the work and CITY TEL. NO.
the structure isd or offered for sale (Section o o.o =7044, Businessions Code). 4 LI 5 0 vOWNERI, as owner of , am exclusively contracting MAIL J. a 2 4=8 5
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code). /
CONSTRUCTION LENDING AGENCY CITY TEL. NO.
�g6 3 b
I hereby affirm that there is a construction lending agency for '
the performance of the work for which this permit is issued CONTRACTOR S o /Al
(Sec. 3097, Civ. C.).
ADDRESS '' ''
Lender's Name I ~G J�
CITY TEL. NO. ✓
Lender's AddressSTATE
I certify that I have read this application and state that the LICENSE NO. 310 l CLASS,
G+ Z
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 above-mentione property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
l0
Signature of Applicant or.Agent _ D e - -