HomeMy Public PortalAbout10324 KEY WEST ST_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
h hereby Uffi•rm that I have a certificate of consent to self
insure, or'a certificate of Workers''Compensbtion Insurance, HEATING - VENTILATING - AIR CONDITIONING
CE-818
or•a certified copy thereof (Sec. 3800, Lab. C.)
CE 818(REV. 10/81)
Policy No. u 3Z Company S A +LIjd CoYMP-
Certified copy is hereby furnished. COUNTY OF LOS ANGELES - BUILDING ND SAFETY
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. ADDRESS
Ji n / f/ (PRINT OR,TYPE ONLY)
Date Applicant EA A oz(o,,-J.49 eat 1 f LOCALITY I -{—
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST , (
COMPENSATION INSURANCE CROSS ST. (-I l I Cn�C
ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED Y
(This section need not be completed if the work involved by
the permit is for one hundred dollars ($100)or less.) Q C/��
AIR HANDLING UNIT, CFM ,�/) (/r
I certify that in the performance of the wo' or which this
permit is issued, I shall not employ any p on in any manner
so as to become subject to the Worke Compensation Laws. BOILER, BTU APPROVALS DATE DATE P oR'S SIGNAT RE
Dare Applica COMPRESSOR, BTU O UO� ROUGH
NOTICE TO APPLICANT: If, fter making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you shoul ecome subject to the Workers'
Compensation prov.i ' ns of The Labor Code, you must forth- EVAPORATIVE COOLER VALIDATI N
with comply with uch provisions or this permit shall be I -
deemed revoked. ' FURNACE: FAUG gy'TY
16 �j
LICENSED CONTRACTORS DECLARATION FLOOR BTU _ / v
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 305 3 I 1 Lic. Class Im
, O
(� v
Contractor n G�DP►JCe 6' Date (0 Aq s �j^ /5 O
❑ i \ t/ U
1 am exempt under Sec. ul
Plan check fee
B.&P.C. for this reason PERMIT ISSUING FEE $ 0 (�
Date: o
Signature' TOTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT ;9 3 2 7, 1 A
I hereby affirm that I am exempt from the ntractor's License ,
Law for the following reason (Section 31.5, Business and NAME # 0 0 0 0 0
Professions Code):
❑ I, as owner of the proper , or my employees with ADDRESS 1 e - 4 4 50
wages as their sole com nsation,will do the work and CITY TEL. NO. 4 U 5 0
the structure is not int ded or offered for sale(Section o 0 o c�
7044, Business an rofessions Code).
❑ OWNER i0,24 y 8 5
I, as owner of e property, am exclusively.coniracting
with licens contractors to construct the project (Sec- MAIL
tion 7044 usiness and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY TEL. NO.�
1 hereby affirm that there is a construction lending agency for ,
the performance of the work for which this permit is issued CONTRACTOR LL
(Sec. 3097, Civ. C.). L
ADDRESS 7 J.
42 V f 1
Lender's Name
CITY' Zu 5 44 TEL. NO.4761-
STATE
Q- ,
Lender's Address l r
I certifythat I have read this application and state that the STATE LIC.
pp LICENSE NO. � 3119 CLASS c` 7-d
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 roperty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
2 9
Signature of Applicant or Agent Dat