HomeMy Public PortalAbout10504 KEY WEST ST_Mechanical__ WOR I(Lttb COMPENSATION DECLARATION r 76A364C - nn �j�jp �7- �p nn
I hereby affirm that 1 have a certificate of consent to self CE'818,(2-80) ; AIT'If L� C A u �O �I F®k P E R II�U T
insure, or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING_ R CONDITIONAIG '
a cei t:fied copy thereof(See.3800,Lab C.)
Policy No Compan
OUi�TY OF LOS ANGELES BALDING AiUD A►FETY
y
,C "
C3 Ccrtifted copy is hereby furnisnetL
Certified Cop' is filed with tt.$4 in¢y,5v ldmg inspection FOR APPLICANT TO FILL'IN BUILDING Q�D Ll`
daiar� ne rt ADDRESS 7
i?ate��� Apphcant !PRINT OR TYPE ONLY)
LOCALITY;
Cj-�RTIFICATV Oh"EXEMPTION FROM WORKERS' NO, TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREST,
COMI?rNSATION'1NSURANC) 't
CROSS ST
(Thus section need not be,completed 1f the York involved ABSORPTION UNIT, BTU
by, the peisnit :s for one-hundred dollars ($100) or.Iess.) DISTRICT NO P ss' ev O
1 cer1liy tb,it in the perTormance of the work for which this AIR`HANOLI�iG UNIT,CFM �/� l/
permit is issued, I shall not employ any person�n any manner V O k , F O
so as to become ubject to the i'ten:°rs'Com ens-tion Laws. BOILER, BTU
APPROVALS DATE I INSPECTOR'S S,IG URE r
Daterd q �pplicant_ COMPRESSOR, BTU ROUGH, WW'
rJOTICl: TO APPLICANT Yf, after mz.Ing this Certificate of VENTILATION SYSTEM FINAL L Z
Exejngtian, won-should become subject to the Workers'
Com nsatrnn piovsions of the LAor Code, you must forth- EVAPORATIVE COOLER" VAL Il]ATION,
wirh comply with such provisions or this, permit Shall be
deemed tevoked, FURNACE FAU `GRAVITY -
LIbFNSED CONTRACTORS DECLARATION FLOG R BTU,
I hereb, affgn that I am licensed under provisions of Chapter HEATER SUSPENDED UNIT
4 (tommencirg O.,ith Section 7000) of Division 3 of the Bust- f W';�1 �d
ness and Professions Code,and riy license is in full force and °
effect,
License rtumver `2�J � L>:c.Class
Contractcr_ �Date �92Y _
l...l ,I ant exempt from the licensing requirements as I am a
lZeensect ,architect or a registered professional engineer I'Plan Check fee 25%of move.
acting in my profegs:onal capacity (Section 7051, Bus- ,z '
mess and Professions Code) PERMIT ISSUING FEE $
Lir: or Rcg.No Date OT ki FEE /7
DOME OWNER-BUILDER DECL'�RATION PLAN CHECK APPLICANT• r
i hereby affirm that I am exempt from-the Codtractoh's NAM w i-
Lsceri i Law for the following reason (Section 7031 5, Busi-
ncsa and Professions Code) AQDRESS
0 7, as owner of,the property, will do the'ivork and the `TEL NO � o-
struttuTe is not intended or offered for sale (Section a CfTY' - 8A_3 A
TY14,.Busini s�apd`Professions Code) : J _ r '
OWNER �'�— — �� k. #;oto,6 *'o'8
E.
I as_tuner of the,property, am exclusively contracting
ith licensed -oaracters to'construct -thep J ect ro MAIL �` (�
(Section'/044,Business dnd Professions Code). ADDRESS �� (�/ _ r 2.or'o .7
CONS'(RUCTION,LENDING AGENCY � CITY �TL NO 'o loo 1 .T0 0,5,
I hereby affirm that there is a construction lending agency — °
for the perf(frmance of the work toy which-this permit is CONTRACTOR � � 2w 8
is Lend t(sec 309T Civ .). ��,�� - i
Lender's t
er's Drame_ - ADDRESS
Under'sAddregs CITY - TEL NO U_) _ 0,-7 g
I certify that T have read this a')phcation and state that the STATE LIC /v
'above information is correct.1 agree to comply with all County LICENSE NO CLASS
ordinances and State taws regulating Heating, Ventilating and q
Air Zonditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County.to enter upon the above-mentioned;property for :.
F—,lt�'ueTen,�V
n!tipf Se°- �.r_iltt¢ee, Data _ _ a