HomeMy Public PortalAbout9253 KEY WEST ST_Mechanical__ • , WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT
ti+hcw�eby affirm that I have a certificate of consent to self
t nsureior a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a-certified copy thereof (Sec 3800, Lab C ) 76A364C
CE-818(REV 10/81)'
Policy No Company
Certified'copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN- BUILDING �53 j/ 5�,,
tion department (PRINT OR TYPE ONLY) ADDRESS �1
Date Applicant LOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST �D #O� 5�
COMPENSATION INSURANCE CROSS S7
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NOPROCESSED BY
the permit is for one hundred dollars ($100)or less.)
I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM `
permit is Issued, I shall not employ any person In any manner
so as to become subject to the Workers'Compensation LOWS I BOILER, BTU APPROVALS DATE INSP S SIGNATURE
to
Date ` 1 Applicant COMPRESSOR, BTU �— r U`� ROUGH
NOTICETO APPLICANT If, after Talon this Certificate f VENTILATION SYSTEM FINAL r
Exemption, you should become suble to the Work r ' _
Compensation provisions of the Labor Co e, you must fo - EVAPORATIVE COOLER VALIDA N
with comply with such provisions or this permit shall be
deemed revoked ' FURNACE 'FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED—UNIT—
(commencing
USPENDED UNIT(commencing with Section 7000) of Division 3 of the Business WALL Q/ l.s
f� 7'
and Professions Code, and my license is in full force and effect %,_000CL
O
License Number Lic Classr
sufrL�l - pop- 09e 0e
Contractor Date �0 5 a Q A V
❑ '1 am exempt under Sec W
Plan check fee # ° • • • 8 d
B 8P C for this reason CA
PERMIT ISSUING FEE 4-24
( ° - 4625 Z
Date _
Signature TOTAL FEE - - 0 4 b 2 5
0 0
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
1 hereby affirm that I am exempt from the Contractor's License /��,��y 0 9,0,1 '-_ 8 8
Law for the following reason (Section 7031 5, Business and NAME PMt5 -7/ J. `,1d` A1 ,
Professions Code) n
❑ I, as owner of the property, or my employees with ADDRES 57
wages as their sole compensation,will do the work and CITY TEL NO
the structure Is not Intended or offered for sale(Section
7044, Business and Professions Code) 0060UJ.
OWNER
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code) ADDRESS
CONSTRUCTION LENDING AGENCY CITY TC TEL NO cq&4V7C!'
1 hereby affirm that there Is a construction lending agency for '
the performance of the work for which this permit is issued CONTRACTOR ,
(Sec 3097, Civ C ) -
ADDRESS
Lender's Name 9
CITY /���.. A) T L O
Lender's Address v� .
STATE ,` LIC
I certify that I have read this application and state that the LICENSE NO C/ol�� CLASS --
above Information is correct I agree to comply with all County
ordinances and State jaws relating to building construction,
and hereby authorize representatives of this County to enter
upon the above-mentioned pro erty for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature pp scant or Agent Do e -