HomeMy Public PortalAbout10342 KEY WEST ST_Mechanical__ WORKER at I have
a cerN DECLARATION APPLICATION FOR PERMIT
.I hereby affirm that I have a certificpte of�consent to self
insure, or a certificate of Workers' Compensation Insurance, 76Ase4c HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec. 3800, Lab. KAJJ
c L �� CE-818(REV. 10/81)
Policy No.�_�ompany
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 le`
tion department. (PRINT OR TYPE ONLY). ADDRESS
Date Z Applicontr�s A.�. LL1r.Cii O�tV yy+ LOCALITY T
A10. TYPE OF APPLIANCE OR EQUIPMENT FEE 1
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. �] PROCESSE BY
the permit is for one hundred dollars ($100) or less.) AIR HANDLING UNIT, CFM
I certify that in the performance oft work for which this
permit is issued, I shall not employ a person in any manner
so as to become subject to the W ers'Compensation Laws. BOILER, BTU APPROVALS DATE INSPECTPR'S SIGNATURE
Dote Appli nt COMPRESSOR, BTU 00 0 � ROUGH10
`
NOTICE TO APPLICANT: , `after making this 'Certificate of VENTILATION SYSTEM FINAL v
Exemption, you sho become subject to the Workers'
Compensation pr sions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATIO
with complysuch provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAV TY
LICENSED CONTRACTORS DECLARATION FLOOR BTU /01 e7d
I hereby affirm that I 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.
cc 1 C'{ TT �
License NumberoJ�I ` Lic:Class c -�V 5:C, 0 ID �� Sd U `
Cdntractor Date (� Z ' O
o� /U �xru
I am exempt under Sec. eae
Plan check fee
B.&P.C. for this reason
Date: PERMIT ISSUING FEE $ S(�
Signature TOTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT'
I hereby affirm that I am exempt from the Contractor's License
Law for the follo/' ended.or
ason (Sec 7031.5, Business and NAME 3 2 6 4 A
Professions Code
❑ I, as ownepro rty, or my employees with ADDRESS # 0 0 0 0 0
wages as tco enation,will do the work and
the structuri ended.or offered for sale(Section CITY TEL. NO. I o.04�I.5p
7044, BusinProfessions Code). OWNER - 0 0 04�l.50v
I, as owneroperty, am exclusively contracting
with licensactors to•construct the project (Sec- MAIL
Tion 7044, and Professions Code). ADDRESS I o,24 $5
CONSTRUCTION LENDING AGENCY CITY TEL. NO.
I hereby affirm that there is a construction lending agency for ►
the performance of the work for which this permit is issued CONTRACTOR r ���
(Sec. 3097, Civ. C.).
6AIADDRESS
Lender's Name I
Lepder's Address CITY TEL. NO. g6`1''51 r
STATE LIC. / c-v-t
I certify that I have read this application and state that the LICENSE NO. C
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
uphe above-mentioned pr erty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
4K J"d4
Q Z
Signature of Applicant or Agent Dai