HomeMy Public PortalAbout10350 KEY WEST ST_Mechanical__ WORKERS' iti DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I have
ave a a c c"rtif cote ,pf'consent to self
inture','or a certificate of Worke s' Compensation Insurance, HEATING --.VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec 13800, Lab C ) 76A364C
G l� C�� CE-818(REV 10/81)
Policy No "1a S O 3�ompan1�j �`1 i - '
Certified copy is hereby furnished COUNTY OF•LOS ANGELES BUIL D SAFETY
Certified-copy is filed with the county buildingIinspec- -FOR APPLICANT TO FILL-IN BUILDING
tion department (PRINT OR TYPE ONLY) ADDRESS ( e, w
Date
Applicant ��r9 AJ C. i!�/J/ LOCALITY -FeI
_ O TYPE OF APPLIANCE OR,EQUIPMENT FEE 1 L-1
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST 1-•�py ,
ABSORPTION UNIT, BTU DISTRICT NO PROCESSED.
(This.section need not be completed if the work involved by
the permit is for one hundred dollars ($100)or less,.) lj
AIR HL
certify that in the performance of the work for which this. ANDLING UNIT, CFM
_
permit is issued, I shall not employ any perr in any manner
so as toy become sublect to the Workers' pensation LOWS BOILER, BTU L.►Q H _ APPROVALS DATE INSP TO S SIGNATURE
COMPRESSOR, BTU `./0�y a � ROUGH �`
Date App�be
cant
NOTICE TO APPLICANT' Iaft making this Certificate of VENTILATION SYSTEM FINAL
- Exemption, you should a subtecT to the Workers'Compensation'provisionsthe Labor Code, you must forth- EVAPORATIVE COOLER VALIDATI N
with comply with such provisions or this permit shall be
deemed revoked FURNACE FAU �{
LICENSED CONTRACTORS DECLARATION FLOOR BTU R VI [ V ab
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 myliic�ense is in full force and effect d
License Number 3 053 1 Lic Class --Cef�
SOQ h1Ge�' 1p 0
Contractor Date 1 s n - O
❑ It
1` ~
I am exempt under Sec
Plan check fee � • d
N
B 8P C for this reason PERMIT ISSUING-FEE $ Z
—,/
Date
TOTAL FEE ;23 2 6'3 A
Signature
OWNER-BUILDER DECLARATION PLAN CHECK•APPLICANT
#$
1 hereby affirm that I am exempt from the Contractor's License o 0 0 0 0l
Law for the followin/intend
(Sectio 031 5, Business and NAME ,
Professions Code) 44,5 0
ADDRESS
ET I, as,owner opert or my employees with 4 4,5 0 C
wages as their e atIon,will do the work and o o,o
the structure is d or offered for sale(Section CITY TEL NO
7044, Business essions Code) OWNER2.4,-8 5
❑ I, as owner of rty, am exclusively contractingwith licensedcs to construct the protect (Sec- MAIL tion 7044, BusiProfessions Code) ADDRESS \
CONSTRUCTION LENDING AGENCYZ
CITY _ TEL NO
I hereby affirm that there is a construction tending agency for, ,
the performance of the work for which this permit is issued CONTRACTOREA
(Sec 3097, Civ C ) -
ADDRESS
Lender's NameQ�L/; )
CITY- ' TEL O_(6`L- 1r
Lender's Address
STATE LIC 6--xe
I certify. that I have read this application and state that the LICENSE NO '3 (7rj� I, •CLASS .• - -. _ -• -• ,
above information is correct I agree to comply with all County
ordinances and State taws relating,to building construction,
and hereby authorize representatives of this County to enter '
u on 0 above
-menti o d property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE. _
0
Signature of Applicant or Agent Do