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HomeMy Public PortalAbout5019 ALESSANDRO AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT ,I hereby affirm that I have a certificate•of consent to self insure,*6r a certificate of Workers''Compensation Ins�ran;e, HEATING - VENTILATING - AIR CONDITIONING or a certified copy thereof Sec. 3800, Lab. C.) 76A364C - 20-0046 DPW 9/88,. Policy No ©�� ��mpany ,, T n/� 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 zy� �hyj n tion department. 1/ P" (PRINT OR TYPE ONLY) ADDRESS Date pplicant /�." t ( 1 LOCALITY llllll/iii NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE 11OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. (This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO, PROCESSED BY the permit is for one hundred dollars ($100) or less.) �o I.certify that in the performance of the work for which this AIR HANDLING UNIT, CFM �j Jc - permit is issued, I shall not employ any person in any manner O G so as to become subject to the Workers' Compensation Laws. BOILER, BTU APPROVALS DATE INSPECTOR'S SIGNATURE Date. Applicant COMPRESSOR, BTU ROUGH y� NOTICE TO APPLICANT: If, after making this 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 deem- ed 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 with Section 7000)of Division 3 of the Business WALL and Professions Code,and my license is in full force and effect. " -7 f� a License Number 5/3 Z Lic. Class r� , O Contractor {.(" .Date d ce ❑ I am exempt under Sec. 0 Plan check fee B.&P.C. for this reason. H Date: PERMIT ISSUING FEE $ Z Signature TOTAL FEE 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): ❑ I, as owner of the property, or my employees with ADDRESS wages as their sole compensation, will do the work and a the structure is not intended or offered for sale(Section CITY TEL. NO. f=(:__�I aF 7044, Business and Professions Code). `;? ❑ OWNER I, as owner of the property,-am exclusively contracting with licensed contractors to construct the project (Sec- MAIL ��/ ��� F j( }jai tion 7044, Business and Professions Code). ADDRESS �ggj 9 ,'r.• 1 a� a 00 CONSTRUCTION LENDING AGENCY : ?,'rE� CITY TEL. NO. �f J- /La I hereby affirm that there is a construction lending agency for v°a t-: I CK the performance of the work for which this permit is issued �r/ , S'` '" P P CONTRACTOR _ (Sec. 3097, Civ. C.). / Q ,` c ' q ADDRESS `' fiP�F3 Lender's Name A " a. Lender's Address CITY TEL. NO. j j;j;('I—i I_ly[' 0/1"p STATE LIC. �/( -" �` � L` I certify that I have read this application and state that the LICENSE NO. j CLASS "' w,413 above information is correct. I agree to comply with all County 33 4 1 AM u o ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter upo Theab ve-menti ned property for inspection purposes. ' SEE REVERSE FOR EXPLANATORY LANGUAGE Si 41ature of Applicant or,Agent Date its