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HomeMy Public PortalAbout10312 KEY WEST ST_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT F herab'y+affirm that I have a certificate �f 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 t CE-818(REV. 10/81) Policy No. S 3� Company �1 ?NS- 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 j.1 tion department. (PRINT OR TYPE ONLY) ADDRESS (<,VU)e-S Date Applicant 5A R 1 R[ l laN/ LOCALITY �e NO. TYPE OF APPLIANCE OR EQUIPMENT FEE .CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. RA 1'fixx ABSORPTION UNIT, BTU DISTRICT NO. PROCES Y (This section need not be completed if the work involved by the permit is for one hundred dollars ($100)or less.) I certify that in the performance of the work for ich this AIR HANDLING UNIT, CFM permit is issued, I shall not employ any perso ' any manner. so as to become subject to the Workers' pensation Laws. BOILER, BTU ,,��ii APPROVALS DATE 5 TOR'S SIGNATURE Date Applica COMPRESSOR, BTU 0 � ROUGHAL NOTICE TO APPLICANT: after making this Certificate of VENTILATION SYSTEM FINAL Exemption, you sho become subject to the Workers' Compensation pr sions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATI N with comply th such provisions or this permit shall be Of deemed rev ed. FURNACE: FAU V GRA T /gyp LICENSED CONTRACTORS DECLARATION FLOOR BTU �iU' I hereby affirm that.1 am licensed under provisions of Chapter 9 HEATER: SUSPENDED—UNIT— '(commencing USPENDEDUNIT'(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 -� Lic. Class 7 1 �_(� �( �c-� poll. ContractoreA S P?�em _e V- Date99 t© ati g5 ` (J �(J ❑ U I am exempt under Sec. r �� A Plan check fee B.&P.C. for this reason PERMIT ISSUING FEE $ ate: TOTAL FEE Signature OWNER-BUILDER DECLAR ION PLAN CHECK APPLICANT I hereby affirm that I am exempt from e Contractor's License , Law for the following reason (Se n 7031.5, Business and NAME Professions CoXnintended n ❑ I, as owpr perty, or my employees with ADDRESS 2 3 2 7,0 A wages asmpensation,will do the work and # o 0 0 0 0 8 the structIntended or offered for sale(Section CITY TEL. NO.7044, Bu Professions Code). 0 04 50 ❑ OWNER e0l' ''L CLAJI, as ownroperty, am exclusively contractingwith liceactors to construct the project (Sec- MAIL o o 0 4 U,5 0 c=) tion 7044, Business and Professions Code). ADDRESS' CONSTRUCTION LENDING AGENCY. CITY TEL. NO. 10,2 4-8 5 1 hereby affirm that there is a.construction lending agency for 6`_363(, the performance of the work for which this permit is issued CONTRACTORr /,t .�,, (Sec. 3097, Civ. C.). �hU Irk ADDRESS 6 /U. �OdY I Lender's Name y (� CITY TEL. NO.. / Lender's Address TI STATE LIC. r �� I certify that I have read this application and state that the LICENSE NO. 06 CLASS Cr 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 abo entioned perty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ,O Zy Signature of Applicant or Agent Date