HomeMy Public PortalAbout9842 KEY WEST ST_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affrrm that I have a certificate of consent to self
Insure, or a certificate of Workers' Compensation Insurance, - HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec -3800, Lab C ) 76A364C I
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
tion department (PRINT OR TYPE ONLY) 'ADDRESS,
Date Applicant LOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE 7'
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST 4L�
COMPENSATION INSURANCE CROSS ST 2
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO PROC SED BY
the permit is for one hundred dollars ($100)or less.)
AIR HANDLING UNIT, CFM
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 become subject To the Workers'Compensate Laws BOILER, BTU APPRO ALS DATE INSPECTOR S SIGNATURE
COMPRESSOR, BTU ROUGH a 7
DaT94_r_tppli
/NOTICE TO APPLICANT If, after making t e Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers' _
Compensation provisions of the Labor Code, you'must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked / FURNACE FAU -,J2&.-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 >.
and Professions Code,and my license is In full force and effect d
License Number Lec Class V
09
Contractor Date V
❑ I am exempt under Sec LU
Plan check fee h
B&P C for this reason PERMIT ISSUING FEE $
Date
TOTAL FEE
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License ,
Law for the following reason (Section 7031 5, Business and NAME
Professions Code)
j, as owner of the property, or my employees with ADDRESS z 9 3 A
wages as their sole compensation,will do the work and CITY T NO # o o e o 0 8
the structure is not Intended or offered for sale(Section • ' ' ' '
7044, Business and Professions Code) OW R 2 0,0 2 0.45 0
❑ j, as owner of the property, am exclusively contracting
MAIL 20,J�Qv
with licensed contractors to construct the project (Sec- o•o;0
tion 7044, Business and Professions Code) ADDRESS
CONSTRUCTION LENDING AGENCY CITY TEL NO G O Jr—8 3
I hereby affirm that there Is a construction lending agency for ,
the performance of the work for which this permit is Issued CONTRACT
(Sec 3097, Civ C ) `
/O� n ADDRESS ;
Lender's Name /�f `E�
CITY trz TEL NO
Lender's Address
STATE LIC ,
I certify that I have read this application and state that the LICENSE NO CLASS
above Information Is correct I agree to comply with all County
ordinances and State laws relating to bulldm onstructeon, _
a d hereby authorize representatives of this ty to enter
u on the ove- do property for in e purp ses 3 SEE REVERSE FOR EXPLANATORY LANGUAGE
195*5 VIA
'Se nature of Applicant or Agent Dote
1