HomeMy Public PortalAbout10380 KEY WEST ST_Mechanical__ ..WORKERS'COMPENSATION DECLARATION 76A364C
I hereby affirm that I have a' certificate of conser t to self CE-818 (2.80) w P P__ UC.AT�O V V FOR F E USC W
insure, or a certificate of Workers'Compensation Insurance,of G�I�sGa�pGtl�i_�1[�SV�TULGa�64�1(s-Q9fF3 ®(�®o'fTo®("D`fnl�
a certified copy thereof(Sec. 3800�L,a6b.�C.)
Policy No!kif rCompany�J_/ 2LZ
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county b l g' spection FOR APPL1CA NT TO FILL IN BUILDING —� y�
.45� _�/"� (PRINT OR TYPE ONLY) ADDRESS JO L E S'/
Date Applicant
LOCALITY /
CERTIFICATE OF EXEMPTION FF M WORKERS' NO, TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSU ANCE. NEARESTCL
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(This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. O
by the permit is for one hundred dollars ($100) oI less.) ' DISTRICT NO. PROCESSE9 BY V
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 �' . O
so as to become subject to the Workers'Compensation Laws. BOILER, BTU
APPROVALS DATE INSPECTOR'S SIGNATURE tU
Date_Applicant ' COMPRESSOR,BTU '` % Z �. ROUGH "'P _Xr N
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM. 177 Z—
-Exemption, you should become subject to the Workers' FINAL ��lei
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER 57-2/-7./ VALIDATIO
with comply with such provisions or this permit shall be L_aPfe�
deemed revoked. FURNACE: FAU_Z_Z'/ GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR: B U
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 Numib-e/r :766'?l _ Lic. Class C
Contractor&6 e �__ Date S-:: .27- OZ
I am exempt from the licensing requirements as I am a
licensed architect or a registered professionat engineer Plat! Check fee 25%of above.
acting in my professional capacity (Section 7051, Bus-
inessPERMIT and Professions Code).
Lic.or Reg.No. Date TOTAL (FEE PL
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-
ness and Professions Code): ADDRESS
1, as owner of the property, will do the work and the TEL. NO. U A
structure is not intended or offered for sale (Section CITY
7044, Business and Professions Code). OWNER # 0 0 0 o (I. 1
1
I, as owner of the property, am exclusively contracting _z>/ t_ �
with licensed contractors to construct the project MAIL i ' 2 0 0 23.00
(Section 7044,Business and Professions Code). ADDRESS G%?S 2 f atxt, � L � r�
CONSTRUCTION LENDING AGENCY CITY TEL. NO. ✓�5 ��� - 27,006
•
I hereby affirm that there is a construction lending agency , Q52.7-81
for the performance of the work for which this permit is CONTRACTOR�r �p I.t!
issued(Sec. 3097,Civ.C.).
Lender's Name ADDRESS I/♦
Lender's Address CITY ' 'v� TE�IINO.
I certify that I have read this application and state that the STATE LIC.
above information is correct.I agree to comply with all County LICENSE NO.J�S I y CI-ASS �: U
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter up n e above-mentioned properly for
msect' n purpo ,s.
Signature of Per ,tt Date