HomeMy Public PortalAbout10425 KEY WEST ST_Mechanical__ `'- R? z S'COMPENSATION DECLARATION 76A364C p o o p o 0 0
I hereby affirm that I have a• certificate of consent to self CE-818 (2-80) Ga p p DC'Q�0 Oo �l FOR p C G3 ��
insure, or a certificate of Workers'Compensation Insurance,or ,HEATING-�y[�NTILATING-AIR CON01TIOn106`G
a certified copy thereof(Sec.3800,Lab.C,)f�
Policy No. C7 Company A_ e22D 1!p�. r
Certified copy is hereby furnished.
COUNTY OF LOS ANGELES BUILDING ARID SAFETY
D Certified copy is filed with the countyb Ire"w'hspection BUILDING
deDartment FOR APPLICANT TO FILL IN ADDRESS
Dat Applicant _- (PRINT OR TYPE ONLY)
LOCALITY .
CERTIFICATE OF EXEMPTION FRC_d WORKERS'17 NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST
(Phis section need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. �U a0
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO, r' PROCESSE BY �. O
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM ! ,} X cc
O
permit is issued, I shall not employ any person in any manner (/CCEIII
so as to become subject to the Workers' Compensation Laws. BOILER, BTU
APPROVALS DATE INSPECTOR'S SIGNATURE `U
Date Applicant f COMPRESSOR,BTU �d �Q ROUGH �6� N
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
deemed revoked. �Q-�
FURNACE: FAU_ — GRAVITY—
LICENSED
LICENSED CONTRACTORS DECLARATION FLOOR: BT/U l!ll
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 Number 20-4 3l 9 Lic.Class_
Contract or.) Da•te�
I am exempt from t,re 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). PERMIT ISSUING FEE $
Lie.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
I, as owner of the property, will do the work and the Z2 5 4 1,.3 A
structure is not intended or offered for sale (Section CITY TEL. NO.
7044, Business and Professions Code). OWNER # 0:010.0 4 1
I, as owner of the property, am exclusively contracting j ��dcr�/ ��' ✓r ��b_/ + 2•a - 27,00
with licensed contractors to construct the project MAIL 1
(Section 7044, Business and Professions Code). ADDRESS /tf�� �i/�M/ NaM'
a o o o 27,00'5
CONSTRUCTION LENDING AGENCY. CITY ' /� TEL.NO.
I hereby affirm that there is a construction lending agencys++ 0 5,2 7. 81
performance of the work for which this permit is
for the CONTRACTOR `
�
issued Sec. 3097,Civ.C.). /J^
Lender's Name ADDRESS
e e E.L.
/
Lender's Address CITY E _ NO. 47/
I certify that I have read this application and state that the STATE .� LIC•' �n .
above information is correct.I agree to comply with all County LICENSE NO v l> f y 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 .pr . above-mentioned property for
inspectpose> -
Signature of Permi.tet Date