Loading...
HomeMy Public PortalAbout5048 ALESSANDRO AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT -11-1-11-1 her�ee by affi+m 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 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 CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. (This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. Y­ PROCESSED BY % the permit is for one hundred dollars($100)or less.) /f AIR HANDLING UNIT, CFM v 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'Compensation Laws. BOILER, BTU APPROVALS DATE IN ECT 'S SIGNATURE Date 3 N1r.Q r 4 Applicant `�+k COMPRESSOR, BTU ROUGH NOTICE TO APPLICANT: If, after making t is Certificate of VENTILATION SYSTEM FINAL Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you.must forth- EVAPORATIVE COOLER VALIDATI dk— 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: SUSPE ED UNIT (commencing with Section 7000) of Division 3 of the Business WALL and Professions Code,and my license is in full force and effect. O License Number Lic. Class , %; Contractor Date O r— ❑ 1 am exempt under Sec. d Plan check fee B.&P.C. for this reason PERMIT ISSUING FEE $ ;2 q q 6.8 A Z Date: TOTAL FEE # 9'0:0 e a 8 Sinnnfii ' OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I ©,a 2 Q 5 O I hereby affirm that I.am exempt from the Contractor's License _. Law for the following reason (Section 7031.5, Business and NAME . �P7\—?( , 0 a 2,Q Jr d v Prpfessions Code): _ ~ ,,\\ o623-88 I, as owner of the property, or my employees with ADDRESS S U � � .��� �6 wages as their sole compensation,will do the work and C � J TEL. NO.'aq Z�S� the structure is not intended or offered for sale Section �i 7044, Business and Professions Code). ❑ I, as owner of the property, am exclusively contracting OWNER with licensed contractors to construct the project (Sec- MAIL tion 7044, Business and Professions Code). ADDRESS CONSTRUCTION LENDING AGENCYCI7y��a, ��:1 TEL. NO.��.�52� I hereby affirm that there is a construction lending agency for mp the performance of the work for which this permit is issued CONTRACTOR (Sec. 3097, Civ. C.). ADDRESS •r UEN� Ilk Lender's Name (('' CIT�'� U TEL NO. js 2� 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 building construction, and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE /I Signature of Applicant or Agent Date