HomeMy Public PortalAbout10360 KEY WEST ST_Mechanical__ W04ZKERS'COMPENSATION DECLARATION 76A364C �p C n �T O Q N FOR
lid E R f�/_1 T
I hereby affirm that I` have a certificate of consent to self
CE -818 (2-80) 6"J 6e /TU U N Cl Ir UAL lr LS,If\S OVIf
insure, or a certificate of Workers'Compensation lnsurancejor HEATING-VENTILATING-AIR CONDITIONING
a certified copy thereof(Sec. 3800,,Lab C)�D
Policy No � Company /�fC 6s' . COUNTY OF LOS ANGELES BUILDING Certified copy is hereby furnished. � BUI LDIiUG ARID SAFETY
',
aCertified copy is filed with the county h Ir' nv gnspection BUILDING y�
d;>ar aft, FOR APPLICANT TO FILL IN' ADDRESS �Q�6 d
Dated Applicant_ ��"�- (PRINT OR TYPE ONLY) /j
LOCALITY /✓4
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE ��
COMPENSATION INSURANCE NEAREST }
(This Section need not be completed.if.the woik involved ^ ABSORPTION°UNIT, BTU CROSS ST a0
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO P CESSSP By (�
I certify that in the performance of,the work.for which this AIR HANDLING UNIT,CFM �i L (% cc
permit is issued, I shall not employ any person in any manner (�a
so as to become subject to the Workers' Compensation Laws BOILER„'BTU
./, APPROVALS DATE INSPECTOR'S SIGNATURE tU
'Date Applicant COMPRESSOR,BTU,?U �/ ROUGH _ N
NOTICE TO APPLICANT If, after making this Certificate of VENTILATION SYSTEMFINAL ����� �+ Z
Ekemption, you should become subject to the Workers'
Compensation provisions of the Labor Code,-,you must forth- EVAPORATIVE COOLERVALIDATION
-with-comply with such provisions or this permlt shall be _ _0&4)
deemed revoked' FURNACE FAU_ Q� GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter HEATER SUSPENDED UNIT
9 (commencing with Section 7000) of Division 3 of the Busi- WALL
ness and Professions Code and my license is in full force and
effect. _
License Number sal Lie.Class
Contractor 6
F1I am, exemp from the licensing requirements-as I am a
licensed architect or-a registered professional engineer Plan Check fee 25%of above.
acting in my professional capacity (Section 7051, Bus-
iness and Professions Code).
Lic.or Reg.No Date TOTAL FEE
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I'hereby affirm that I am exempt from- the Contractor's NAME
License Law for the following reason (Section 7031.5, Busi- ;9,5 4 1,•6 A
-ness and Professions Code). ADDRESS
0 I, as owner of the property, will do the work and the TEL. NO. #:o,0'6 o 4,1
structure is not- intended or offered for sale (Section CITY
7044, Business and Professions Code) 2'0 0 27,0 0
OWNER fj�''+
,I, as owner of the property, am exclusively contracting !aL/-h/
a_��—p�U` , 11 o•0 0 2 7 0 01M
with licensed contractors to construct the project MAIL �7�r
(Section 7044, Business and Professions Code). ADDRESS A/v7 of/ /��{�� � to ” O a 2 7
1_8 1
CONSTRUCTION LENDING AGENCY . CITY YCc�!`�f� TEL. NO yAI`3 -o�C7O -
I hereby affirm that there is a construction lending agency CONTRACTOR
for the performance of the work for which this permit is
issued(Sec 3097,Civ.C.).
Lender's Name ADDRESS Al '
Lender's Address CITY ^vs.� TEL. NO. 5V
I certify that I have read this application and state`that the STATE 1 �0��� C ASS
above information is correct. I agree to comply with all County LICENSE NO
Ordinances.and State laws,regulating Heating, Ventilating and
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter icor A above-mentioned property for
In ec�tion purpo.e
Signature of Pe nit Date _