HomeMy Public PortalAbout10405 KEY WEST ST_Mechanical__ WORKERS'COMPENSATION DECLARATION y CEA 81 8 (2-80) AP P LL C A V ON FOR P E R WT
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
a certified copy thereof(Sec 3800 ab C -f-
Policy No7l8 Company ��� S `rO�j� i(/�• / r ��
Certified copy is hereby furnished COUNTY OF LOS,ANGELES BUILDING AND,SAFETY
Certified copy is filed with the county b il i nspection BUILDING �^—
d���'''artment FOR APPLICANT TO FILL IN gDDRESS �(�yp �•kt� _
Dates �` �f Applicant L - (PRINT OR TYPE ONLY)
• LOCALITY
CERTIFICATE OF EXEMPTION.FROM WORKERS' NO TYPE OF APPLIANCE OR EQUIPMENT FEE —
COMPENSATION INSURANCE , NEAREST f
(This-section need not be-completed if the work involved ABSORPTION UNIT, BTU CROSS ST a0
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO PROCESSED Y ; f>
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM �/Q O
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws • BOILER, BTU
APPROVALS , DATE INSPECTOR S SIGNATURE U
Date Applicant COMPRESSOR,BTU-0-0 QQV Q ROUGH �" N
NOTICE TO APPLICANT If, after making this Certificate of VENTILATION SYSTEM FINAL 07y Z
Exemption, you should become subject to the Workers'
Compensation provisions of-the Labor Code, you must forth- EVAPORATIVE COOLER
VALIDATION
with comply with such provisions or this permit shall be
deemed revoked FURNACE FAU4�� GRAVITY
LICENSED CONTRACTORS DECLARATION - FLOOR BBB U
I'hereby affirm that I am licensed underprovisions of Chapter HEATER SUSPENDED UNIT �5- 771
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
J d�S� �� Lib Class v a
Contractorfr-dc' �✓/�J Date 5 8�
I am exempt 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 7
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 CITY TEL NO
structure is not'intended or offered for sale (Section
7044, Business and Professions Code)_
OWNER ��✓= ��r
•-� d, as owner of the property, am exclusively contracting J'�_�L'�_1�_ " ;?,5 4 Q 6 A
with licensed contractors to construct the project MAIL //� .�y/
77
(Section 7044,'Businessand Professions Code) ADDRESS /y � �. Ia�.� t [i
' TEL NO �j�i��,�( o� #.0 0 0 0 1,CONSTRUCTION LENDING AGENCY CITY A�d
I hereby affirm that there is a construction lending agency i 2'o 0 2 7,0 0
for the performance of the work for which this permitis CONTRACTOR
issued(Sec 3097,Civ C) _ v o.0 0 2 70 Q 2:�
Lender's Name ADDRESS 26 /i/ O ce
Lender's Address CITY /-d !I S EL NO ,c%I� A.27-
I certify that I have read this application and state that the STATE -� /� LIC -a O
above information is correct I agree to cbmply with all County LICENSE NO 30� CLASS
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
Countyto enter on above-mentioned property for -
m�i purpos
Signature of Per, ttee Date