HomeMy Public PortalAbout10420 KEY WEST ST_Mechanical__ WORKERS'COMPENSATION DECLARATION 76A364C /n� P FIg �C !.� T�O N FOR R PER(\/1 T
I hereby affirm that I have a certificate of consent to self CE-818 (2-80) hl ISs \4s 6�1 II CI I� {f\S I� IJP uva
insure, or a certificate of Workers'Compensation Insurance,or HEATING CONDITIONING
a certified copy thereof(Sec 3800,Lab P) 7—�
Policy No y�` Company -9 CLIe,Z- COUNTY OF LOS ANGELES �-
/ dool BUILDING AND SAFETY
F1Certified copy is hereby furnished
Certified copy is filed with the county buil n ction BUILDING
FOR APPLICANT TO FILL IN ADDRESS
dL�part en (PRINT OR TYPE ONLY)
Date) a � Appltcant LOCALITY G
CERTIrICATE OF EXEMPTION FROt WORKERS' NO TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCECL
NEAREST r }
(This section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST 0
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO 1 ROCESSED Y 0
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM (' { O cc
permit is issued, I shall not employ any person in any manner ,U Q 0
so as to become subject to the Workers' Compensation Laws BOILER, BTU ~'
APPROVALS DATE ,INSPECTORS SIGNATURE IU
Date Y Applicant COMPRESSOR,BTU 36 ROUGH '� tan
NOTICE TO APPLICANT If, after making this Certificate of VENTILATION SYSTEM FINAL Z
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be ! 00 O
deemed revoked FURNACE FAU[`� GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU 0 S7
I hereby affirm that r am licensed under provisions of Chapter HEATER SUSPENDED UNIT
9 (commencing with Section 7000) of Division 3 of the Bust- WALL
ness and Professions Code, and my license is in full force and
effect ��,G
License Number ��� Lie Class C-.'?0
Contractore�,$_•�' Date
ElI 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-
mess and Professions Code) PERMIT ISSUING FEE $
Lie or Reg No Date TOTAL FEE
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that 1 am exempt from-the Contractor's NAME
License Law for the following reason (Section 7031 5, Busi-
ness and Professions Code) - ADDRESS
I, as owner of the property, will do the work and the TEL NO
structure is not intended or offered for sale (Section CITY
7044, Business and Professions Code)
OWNER �F✓
I, as owner of the property, am exclusively contracting a r /(,�/l/ O✓
with licensed contractors to construct the project MAIL
(Section 7044, Business and Professions Code) ADDRESS
TEL NO °�9 3 25402A
CONSTRUCTION LENDING AGENCY CITY, �� 80
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is CONTRACTOR # o)o o'o 4
issued (Sec 3097,Civ C)
in
Lender's Name ADDRESS 7� n/, 6Y .i 2 ro 0 2 7 Q 0
Lender's Address CITY „ —Gi '?E NO2 ] Q Q v
i certify that I have read this application and state that the STATE-' t� LIC /� (J
above information is correct I agree to comply with all County LICENSE NO w �/ CLASS ` 'Z Q Jr 2 7' 8
ordinances and State laws regulating Heating, Ventilating and
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter ip n he above-mentioned property for
inspect t purpo a `r �, 7 _�/ - - - - -
Signature of Pe i ee Date ,