HomeMy Public PortalAbout9252 KEY WEST ST_Mechanical__ WURKER'SCOMPENSATION DECLARATION 6DPW9,69
76A36APPLICATION FOR PERMIT LIME GREEN
76A364C
I hereby affirm that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified HEATING=VENTILATING•AIR CONDITIONING
copy thereof(Sec. 3800 Lab. C.)
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cy No. Company COUNTY OF LOS ANGELES DEPT OF'PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
❑, Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING
department. (PRINT OR TYPE ONLY) ADDRESS
Date Applicant LOCALIT f
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
ABSORPTION UNIT,BTU ASSESSOR
(This section need not be completed if the.work involved by the
permit is for one hundred dollars($100)or less.) MAP BOOK PAGE PARCEL
AIR HANDLING UNIT,CFM DISTRICTPBOO. PRocesseD ev
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 D �i
become subject to the Workers'Compensation Laws. a
COMPRESSOR,BTU sMg
Date Applicant VENTILATION SYSTEM APPROVALS DATE INSPECTOR'S SIGNATURE
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 GRAY.WY
LICENSED CONTRACTORS DECLARATION f FLOOR BTU SS VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL '••••'� a -
Professions Code, and my license is in full force and effect.
E V 3.7 ;-s
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License Number Lic.Class
_ _ }
Contractor Date
Ll1 AL :L -1 0 = I'°-
❑ I am exempt under Sec. Plan Check fee #} i
—
B.&P.C.for this reason PERMIT ISSUING FEE
Date: TOTAL FEE U
/l I I.11, I�—i it 0� W
Signature s �;�._11j�'=%
PLAN CHECK APPLICANT
OWNER-BUILDER DECLARATION 45607 1.:.;Z
fifi� o t__
I hereby affirm that I am exempt from the Contractor's License Law NAME ! �
for the following reason (Section 7031.5, Business and Professions / C
Cod ADDRES ,/ '�-}��--
I, as owner of the property, or my employees with wages 1 r ��S
as their sole compensation, will do the work and the CI /_ .t T TEL.NO. 08
structure is not intended or offered for sale (Section 7044, "c O
Business and Professions Code). OWNER s '
❑ ZL
I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS I l
tion 7044, Business and Professions Code).
CITY I TEL.NO.
CONSTRUCTION LENDING AGENCY •
I hereby affirm that there is a construction lending agency for CONTRACTOR
the performance of the work for which this permit Is issued S•&fL '
(Sec. 3097,Civ.C.).
ADDRESS
Lender's Name
CITY TEL.NO.
Lender's Address STATE LIC.
I certify that I have read this application and state that the above LICENSE NO. CLASS
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
representatives of this County to enter upon the above-mentioned
pro rty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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SI N TURE O APPLICANT O AGENT I ioODATE