HomeMy Public PortalAbout9219 KEY WEST ST_Mechanical__ WORKER'S COMPENSATION,DECLARATION 20-0046 DPW 9/89 . I a `�#M E GREEN,
76A-%4C :APPLICATION FOR'PERMIT
I hereby affirm that,I have a certificate of consent',to'self Insure, `
or a certlfic0tetof Worker's Compensation Insurance, or"a certified_; HEATING- VENTILATING -AIR CONDITIONING '
copy thereof(Sec 300 Lab C) sc
e�
Policy No Z; ��Company -��%- COUNTY'OF LOS ANGELES DEPT OFf PUBLIC WORKS BUILDING AND'SAFETY DIV.
❑ Certified copy'is•hereby furnished
Certified copy is flied wrth't 'count IIg inspection ; FOR APPLICANT-TO FILL IN &-`` ' BUILDING;
r-department , _ _ (PRINT OR'7PE ONLY) ,� ADDRESS
�� �✓ ry
Date - NEAREST
Apphca LOCALITY^ t
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTIO FROM WORKERS' ' t CROSS ST-
COMPENSATION INSURANCE ;
s ABSORPTION UNIT,BTU '
+, ASSESSOR e' •
(This section need,not be completed if the work involved by the ` MAP•BOOK �d PAGE PARCEL
peimit.is for one`hundred dollars($100)or less) AIR'HANDLING'UNIT,CFM'
• DISTRICT NO' _ PROCESSED eV 1" 5.J
I certify that In the'performance of the work for which this permit
Is Issued, I shall`not employ any person In any manner so as to BOILER,BTU jt G y
become subject°to the Workers' Compensation Laws
COMPRESSOR,BTU'
" 4 '-APPROVALS DATE INSPECTORS SIGNATURE
Date Applicant VENTILATION SYSTEM
_NOTICE TO+'APPLICANT If, after_making this' Certificate'of - ROUGH
Exemption,you'should become subject to,the Workers:Compensation, EVAPORATIVE COOLER
-provisions of the Labor Code, you must forthwith-comply with such FINAL' �:' 0
r
provisions or`this permit shall be deemed revoked = FURNACE FAU GRAVITY
LICENSED CONTRACTORS DECLARATION I I FLOOR BTU '' =a' VALIDATION. -
I heieby affirm that I am licensed under provisions of Chapter 9 SUSPEN ED UNIT �r
(commencing with Sec`tlon 7000) of'Divlslon 3 of,the Business and -
HEATER y/ALL
°Professions'Code and"niy license Is°In full-for' and effect v
License Number �"' Lic,ClassC2-;e&-1, '
QCT. o
Contractor Date � �
Elmx
I aempt un er Sec, Plan check fee ; 3cc V
B&P C for this reason PERMIT ISSUING FEE$ r V ITEMS �.
Date TOTAL` FEE' T(ITAL z 50 ®t5 V
Signature 59.r.-yc- Q-
5 PLAN CHECK APPLICANT ',
Ig
OWNER-BUILDER DECLARATION ' r II} Z
Thereby affirm that.l'am,exempt from the Contractor's License•Law NAME � j� +~ e: . ., 1
for the following reason (Section,7031'5, Business and Professions z
Code)' es aN ,a.• '-1 ADDRESS <� //'f coo------+ it F ii t '
❑ I, as owner of the property, or
my'e`m'ployees with w+ages �} " [Illl_I�"�I[I j 3415/?.�
as their"sole compensation; will'do`the work and the CITY TEL''NO ;s %- ' C q
structure;is not intended or'offered for,sale (Section 7044; u�•j� i= r1!!z
Business and Professions Code)' xs OWNER } f*
EJ1, as-owner of the'property, arn'•exilusively contracting MAIL -i`
with licensed contractors to construct°the project (Sec- ADDRESS
tion 7044,rBusiness and Profession's Code)f• - r - - xs• +
CONSTRUCTION LENDING AGENCY" ' CITY TEL NO
I I hereby affirm'that there,is.,a construction lending'agency for-
the'
- - - -
the'pe"rformance'of the work for which this permit,`Is issuedfA
ONTRACTOR
, -,(Sec 3097, Civ C) �' k, r
DDRESS ��r //%fit ;• -'
°Lender's Name
a CITY' TEL NOS/d C. J �ul, -f, , •Vr,a_ -
Lender's Address = STATE LIC
.'I certify that I have read this'applicatl , ntl state that the above LICENSE NO CLA
onSS
information Is correct 1 agree'to comply with;ally,County ordinances
' and State laws relating to'bwlding construction,and hereby authorize "j • -'` j _ '�
representative f this County`to enter upon the above-mentioned
ro art r s action ur�oses
p p r p p SEE REVERSE FOR EXPLANATORY LANGUAGE l r
SIG
GENT _ _ ATE ' ,