HomeMy Public PortalAbout10319 KEY WEST ST_Mechanical__ WORKERS'. Ihave COMPENSATION DECLARATION APPLICATION FOR PERMIT
hereby affirm that I have a certificate of consent to self
in'sure,'or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec. 3800, Lab. C.) 76A364C
r CE-818(REV. 10/81)
Policy No. &:f 3-z Company SkBJk. �"4 (01,P� COUNTY OF LOS ANGELES BUILDIN A SAFETY
Certified copy is hereby furnished.
Certified copy is filed with the county building.inspec- FOR APPLICANT TO FILL IN BUILDING } /f
tion department. 1/ /� / (PRINT OR TYPE ONLY) ADDRESS
Date Applicant —A A i R ((t.J `-/Y,_oW LOCALITY �
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
(This section need not be completed if the work' olved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED Y
the permit is for one hundred dollars ($100) ess.)
I certify that in the performance�thherk for which this AIR HANDLING'UNIT, CFM Dpermit is issued, I shall not emploon in any manner
so as to become subject to the Wmpensation Laws. BOILER, BTU APPROVALS DATE IN OR'S SIGNATURE
COMPRESSOR, BTUYg"000
ROUGH'
Date' Applicant
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: ;AU GRAY TY /FA
01
LICENSED CONTRACTORS DECLARATION r FLOOR BTU (/
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED-UNIT-
(commencing
USPENDED UNIT(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code,and my license is in full force and effect.
-'C� O
License Number '30s-319 Lic. Class
6��-F�rN dot d
( 2y ,
Contractor sG@v C3 Date 5 O p.
❑ 1 C
I am exempt under Sec.
Plan check fee
B.&P.C. for this reason' PERMIT ISSUING FEE Q
Date: -.223269A
Signature TOTAL FEE # 0 0 0 0 0
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from Contractor's License
ason (Sec ,
Law for the following ren 7)3 1.5, Business and NAME o o 4,[L 5 0
Professions Code):' -
❑ I, as owner of the I erty, or my employees with ADDRESS - 44,5002:
wages as their sole co pensation,will do the work and
the structure is not i ended or offered for sale(Section CITY TEL. NO. G24-85
7044, Busine/anProfessions Code). OWNERI, as owner roperty, am exclusively contracting
with licenseactors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY TEL. NO.,2g'4,
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTOR E' r ,
(Sec. 3097, Civ. C.). O
ADDRESS 7.Z 4 AJ
Lender's Name
CITY TEL. N .
Lender's Address (I l
STATE �^ LIC. r6
I.certify that I have read this application and state that the LICENSE NO. �7V 3 � CLASS
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
ups:theiove-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
1012-
Sig-n.ature
O 2Signature of Applicant or Agent D e