HomeMy Public PortalAbout10311 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, Lab. C. 76A364C
j JJ CE-818(REV. 10/81)
,.Policy No.� Company STAB RATA CoO P.
COUNTY OF LOS ANGELES BUILDING SAFETY
Certified copy is hereby furnished.
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. � (PRINT OR TYPE ONLY) ADDRESS
i n
Date f0 2'y Applicant LAS /�iQ ` (ONI LOCALITY
r!
O. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED
(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 G
I certify that in the performance of the w ik for which this
permit is issued, I shall not employ any son in any manner
so as to become subject to the Work 'Compensation Laws. BOILER, BTU APPROVALS DATE IN TOR'S SIGNATURE
l COMPRESSOR, BTU q'g � ROUGH
Date Applic
NOTICE TO APPLICANT: If after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you shoul become subject to the Workers'
Compensation provis' ns of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDA ON
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAV TY g� /�
LICENSED CONTRACTORS DECLARATION FLOOR BTU �. (� (!
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 4 3 R Lic. Class �02 4 / op
uct. "
Contractor Date t'O IO '
❑ 0 U
I am exempt under Sec. UJ
Plan check fee H
B.BP.C. for this reason PERMIT ISSUING FEE a
Date:
Signature TOTAL FEE
OWNER-BUILDER DECLA TION PLAN CHECK APPLICANT ;?3268A
'
I hereby affirm that I am exempt fro e Contractor's License , # 0 0 o o o 8
Law for the following reason (Se on 7031.5, Business and NAME
Professions Code):
❑ I, as owner of the pro erty, or my employees with ADDRESS. 1 o o 4 IL5 0
wages as their sole co pensation, will do the work and CITY '. TEL. NO. o 0 - 41L50'
the structure is not i ended or offered for sale(Section
7044, Business a Professions Code).
OWNER❑ aN I Q 2 4 3 8 5 I, as owner o e property, am exclusively contracting
with licens contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY TEL. NO. -a
1 hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.). ! t
ADDRESS O (Ci.
Lender's Name
CITY Z TEL. NO. 96 IF-511 t
Lender's Address I
STATELIC.
3 �
I certify that I have read this application and state that the LICENSE NO. � CLASS C,..- •`►(j
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-mentioned roperty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
�O Z
Signature of Applicant or Agent Dote