HomeMy Public PortalAbout10410 KEY WEST ST_Mechanical__ WORKERS'COMPENSATION DECLARATION CE 81 C "8 (2-80) LL" . pPER
I"hereby affirm that I have a certificate of consent to self CE -81 �`>r�� ®�V ®� ��Il ��
insure, or a certificate of Workers'Compensation Insurance,or HEATING-VENT ILATING-All R CONDITIONING'
a certified copy thereof(Sec 3800 La �Cf') .1 _
Policy No Company� / fJ _i,� - • •, �
COUNTY OF LOS ANGELES R f BUILDING AND SAFETY
t � Certified copy is hereby furnished • - „ '
Certified copy u filed with the cou�tl _ ection8UILDING �����d�artme t FOR APP,L'ICANT TO FILL IN Date A hcant_ • (PRINT OR TYPE.ON{_Y) ADDRESS P✓�
pP
' • ; LOCALITY
CERTIFICATEsOF EXEMPTION FROM WORKERS; NO TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST
(This seCtiOn'need not be completed if the work mvoh+ed. - ABSORPTION UNIT,
�STu CROSS ST - i• O•
by the permit is for one hundred dollars ($100) o ,less.) DISTRICT-NO. PFiOCESSE 8Y (�
I certify that in the performance of,the work'for w,h ch this` AIR,HANDLING UNIT;CFM (/ 0
permit•is issued, I shall not employ any person in any-'manner = 0 O
so as to become subject'to the Workers' CompensatioLaws BOILER, BTU
APPROVALS DATE , INSPECTOR S SIGNATURE
Date Applicant ° lJJ
COMPRESSOR, BTU_ ROUGH �' " N
NOTICE TO APPLICANT If, after making'this Certificate of" VENTILATION SYSTEM, -FINAL ��O' ms
..Exemption, you should become subject to'the Workers'
Compensation provisions.of the,Labor'Code, you must'forth- VALIDATION
EVAPORATIVE COOLER,' '
with comply with such previsions,or this permit 'shall be , -
deemed revoked -��
FURNACE_ FAU. / GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BtU L>
I hereby affirm-that'I am licensed under provisions of Chapter HEATER SUSPENDED UNIT-
9 (commencing with Section 7,000),of Division-3,6f the°Busi-• WALL
ness and,Professions Code, and•my license is in full,force and
effect _
License Number US LIC Class (D0-�2
Contractor 1�',Fel�icensmg
Ddte I am exemp from t- requirements as I am a
i hcensed architect or a registered professional engineer Plan Check fee 25%of above
acting in*my professional capacity (Section 7051, Bus-
iness and Professions Code). 4 PERMIT ISSUING FEE $
Lie or Reg No Date 'TOTAL FEE
HOME OWN ERI-BU ILDER 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, Bust- z
ness and Professions Code) ADDRESS x
I, as owner of the property, will do the work and the, ;9'5,4 Q'5,A -
structure is not intended or offered,for sale (Section, CITY TEL NO i
7044, Business and Professions Code), _ a #lo o`o<• 4.1
i OWNER r [ � �( i
I, as,owner of the property, am exclusively contracting- r'a� r !�a vt°�� 2 -,-,2 OV,
with hcensed,contractors to construct- the project', MAIL r �' I ' • ,
-(Section 7044, Business ar&Professioits Code) ADDRESS �y�o E/�/�� r3 ti' —
CITY TEL.NO '45 :� U
CONSTRUCTION LENDING AGENCY _ ��'a��t�t � 5 2l_8 T,
I hereby affirm that there is a construction lending agency • e
for the, performance of the work for which this permit'is CONTRACTORC,� �!
issued(Sec 309,7,Civ C) 4��
Lender's Name ADDRESS ' r✓ Qk
Lend er'sAddress CITY TEL NO
I certify that I have read this application,and state that theST-ATE LIC
above information is correct.I agree to comply with all County LICENSE NO 30__3 CLASS
ordinances and State laws regulating Heating, Ventilating and -
Air Conditioning, and hereby authorize representatives of this, SEE REVERSE FOR�EXPLANATORY•LANGUAGE
County to enter upo above-mentioned property for + -
ins ect n pure es
Signature of Per; i tom Date `g� -.t � -' i� - _ - •a T