HomeMy Public PortalAbout10336 KEY WEST ST_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I have a certificate pf 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
yy���// 3 Z ;( � ����� CE-818(REV. 10/81)
Policy No.4i'a7�Company R 2 `
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDI AND SAFETY
' Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. ADDRESS, e
L_ /� (PRINT OR TYPE ONLY)
Date C o Applicantcd; •7Jnc C.,,A��roiV LOCALITY
O. TYPE OF APPLIANCE OR EQUIPMENT . FEE !! t
&RTI KATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE. CROSS ST.
ABSORPTION UNIT, BTU DISTRICT NO. 1 PROCESSED BY
(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 which this AIR HANDLING UNIT, CFM
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers' ompensation Laws. BOILER, BTU APPROVALS DATE IN E TOR'S SIGNATURE
COMPRESSOR, BTU / "� ROUGH
Date Applicant
NOTICE TO APPLICANT: If, after aking this Certificate of VENTILATION SYSTEM FINAL -
Exemption, you should beco e subject to the Workers'
Compensation provisions of e Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such ovisions or this permit shall be
deemed revoked. FURNACE: FAU G ITY /{ /�
LICENSED C NTRACTORS DECLARATION FLOOR BTU (J 011
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.
License Number 17 Lic. Classes C ► V
Contractor ZWgneNCQ Date to i`! r
- f U
❑ I am exempt under Sec. L"
B.&P.C. for this reason Plan check fee �
PERMIT ISSUING FEE $
Date:
Signature TOTAL FEE
OWNER-BUILDER DECLARAT N PLAN CHECK APPLICANT
I hereby affirm that I am exempt from th ontractor's License
Law for the following reason (Sectio 031.5, Business and NAME
Professions Code): �c 3 2 6 5 A
❑ I, as owner of the prop y, or my employees with ADDRESS
wages as their sole com msation,will do the work and # 0 0 0 0 0 8
CITY TEL. NO.
the structure is not int ded or offered for sale(Section
7044, Business and rofessions Code). ) ° ° 4 4 5 0
OWNER d
❑ I, as owner of t,b'e property, am exclusively contracting MAIL ° ° 044,5020:
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code). ( 2 4 8 5
CONSTRUCTION LENDING AGENCY CITY TEL. NO. �6_ O.
I 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.). s0�1/�.t!
ADDRESS y
Lender's Name
CITY .4TEL.
Lender's Address
STATE LIC.
I certify that I have read this application and state that the LICENSE NO. QS CLASS
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize reJpr
IVes of this County to enter
upon ab entionrty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE -
Signature of Applicant or Agent Date