HomeMy Public PortalAbout10656 KEY WEST ST_Mechanical__ WOR'ER:$COMPENSATION DECLARATION 76A366DPW9/89 APPLICATION FOR PERMIT
I hereby.affum tjh t,I have'a certificate of.consent to self Insure, 76A364C LIM F..-GREEN ,
or'a certificate of Wdrker's Compensation Insurance, or a certified " HEATINGVENTILATING -AIR CONDITIONING
copy thereof(.Sec 3800 Lab. C.)
Pohcoto._Z g���3- Company' COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS :`' BUILDING AND-SAFETY DIV.
Polls
Certified copy is hereby furnished.
Certified co Is filed with the count building inspection FOR APPLICANT TO FILL,IN; BUILDING, t '
department. ' y g p (PRINT OR TYPE ONLY) ADDRESS
Date Applicant -LOCALITY-. s,
NO TYPE OF APPLIANCE OR EQUIPMENT *- - _ FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' '- NEARESTQ^`/Z/ypiyTe
v�
• •COMPENSATION INSURANCE CROSS ST �
ABSORPTION UNIT,BTU ASSESSOR•
(This section need not be completed If the work Involved by the MAP,BOOK PAGE- PARCEL
permit Is for one hundred dollars($100)o�less;) AIR HANDLING UNIT,CFM
' DISTRICT NO _ -, PROCESSED BY
certify that In the performance of the work for which this permit -
is issued, I shall not employ any.person in any manner so as to BOILER,BTU y G
•..'become subject to the Workers'Compensation Laws. -
'COMPRESSOR,BTU CJ O(!a
- APPROVALS - 'DATE' INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE-TO APPLICANT. If, after making this'Certificate of ROUGH
Exemption;you should become subject to the Workers'Compensation EVAPORATIVE COOLER =
provisions of the'Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE. . FAU RAVITY "' /
LICENSED CONTRACTORS DECLARATION " / FLOOR BTU (!� O VALIDATION ;
I hereby affirm that I am licensed under provisions of Chapter 9SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL
'Professions Code,and my license is in full force and effect U
License Number Lic.Class
/l L7YRN C919 L }
Contractora4 �O�Na, � /AidDate'
JL
Plan'check fee ACCT.,: V
I am exempt under Sec. ''^ ^ Q
B.&P.C.for this reason PERMIT ISSUING FEE$ JJ�J ' I g7.J�
- � _ 1�ITECIS
Date TOTAL'FEE. Q - W
Signature ?% TOTAL 97 _' 30 a
PLAN CHECK APPLICANT 'CHECK
OWNER-BUILDER DECLARATION 97.j0 co
I hereby affirm that I am exempt-from the Contractor's License Law NAME CHANGE-`- .00 '
for the following reason (Section 7031.5, Business and Professions
• Code): ADDRESS " t, '
• I, as'owner of the,property, or my'employees with"wages (� —�0i 4I2'Ft IgO
as their sole compensation, will do'the work arid the CITY TEL.NO ;
structure is not Intended or offered for sale (Section 7044,• [rM 5-30,
Business and Professions Code). OWNER t, .. `•�� �. 1 ..F . ,
/�M'K6 P I S•CA Tozz i�'
I, as owner of,the property, am exclusively contractiri'g MAIL
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044,-Business and Professions Code) � - - '
CONSTRUCTION LENDING AGENCY CITY ��„ �c /1 ��. TEL NO 4113-& 7�
I hereby affirm that there Is a construction lending agency for CJ
the, performance of the CONTRACTOR work for which this permit is issued Qi,�, O�NQO/P/1• /we
(Sec.3097,Civ. C)
ADDRESS
Lender's Name sq/� !�T 7T—I�7✓ •,
' CITY �Vy/�i1f��A TEL NO .. - .
Lender's Address STATE' C-6
LIP /f ;
I certify that I have read this application and state that the above LICENSE NO ;2 _X6 v ZD
information is correct. I agree to comply with all County ordinances CLASS
and State laws relating to building construction,and hereby authorize
representatives of this County to enter upon the above-mentioned -
property for inspection arpcses. SEE REVERSE FOR EXPLANATORY LANGUAGE ~
INONATURE OF APPLICANT OR 4GV4T DATE - -