HomeMy Public PortalAbout10400 KEY WEST ST_Mechanical__ WOICKERS'COMPENSATION DECLARATION CEA 818 (2-80) A If- P LSv C A 0 B®t'rl FOR P E R Wu
I~hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR ATING-AIR CONDITIONING
a certified copy thereof(Sec 3800,Lab CC))
opy
Policy No 6_0 NS, �,
Certified c1erebYfurnished COUNTY OF LOS ANGELES BUILDING ARID SAFETY
Certified copy is filed with the county buildin i tion FOR APPLICANT TO FILL IN BUILDING
arti�ent ADDRESS
Date, *Wk Applicant _ (PRINT OR TYPE ONLY) '
" LOCALITY
CERTIFICATE OF EXEMPTION FROM ✓O ERS' NO TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST }
(This section need not be completed if the work uivolved ABSORPTION UNIT, BTU----&.CROSS ST a0
by the'permit is for one hundred dollars ($100) or less.) DISTRICT NO ROCESSFP By ,_ U
I certify that in the,performance of,the,work for which this AIR HANDLING UNIT,CFM J �d
permit is issued, I shall not employ any person in any manner O0
so as to become subject to the Workers' Compensation Laws BOILER, BTU
APPROVALS DATE INSPECT S SIGNATURE IU
Q �D CL
Date Applicant COMPRESSOR,BTU�� ROUGH �' "' N
NOTICE TO APPLICANT If, after making this Certificate of VENTILATION SYSTEMFINAL , Z
Exemption, you should become subject to the Workers'
Compensation provisions oftthe Labor Code, you must forth- EVAPORATIVE COOLER Gv ., 'VALIDATION
,with comply with such`provisions or this permit shall be
deemed revokedFURNACE FAU—_ GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR B_U /o,
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 l
License Number��`S? Lic Class � (]
��
Contractor $ if _ Date S 7
I am exempt from t e 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-
ness and Professions Code) ADDRESS
1, as owner of'"the property; will do the work and the a CITY TEL NO structure is not intended or offered for sale (Section
7044, Business and Professions Code)
OWNER I
e,
I, as owner of the property, am exclusively contracting a� � � e V.
with licensed contractors to construct the project MAIL
(Section 7044, Business and Professions Code) ADDRESS 5 , /t/i G a
CONSTRUCTION LENDING AGENCY CITY �� C a TEL NO Z y,_ 2e03 Y,5 4'0.3 A
I hereby affirm that there is a construction lending agency #' LI
for the performance of the work for which this permit is CONTRACTOR i `oa N to o'o+o
issued. Sec 3097,Civ C
Lender s Name ) ADDRESS d 2 0 to 2700
Lender's Address CITY TE NO �f to oto 2 7,0 0'5:
96 -.s
I certify that I have read this application and state that the STATE , C` LIC a 6 O'S 2,7-8,1
above information is correct I agree to comply with all County LICENSE NO 3 ���� CLASS �`
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning, nd hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to ent up a above-mentioned property for-
a ec n purp IS. �8 •
ignature of Per i . Date ti