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HomeMy Public PortalAbout5510 ALESSANDRO AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT I hereby gffirm that I have a certificate of consent to self insure,%or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING ora ce ti le copy thereof (Sec. 3800, Lab. C.) 76A364C <4'Qelf'dA, F-120-0046 DPW 9/88 .Policy o. Company J Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY epy e county ung nspec- ® Certified cois filed with thtbuilding iFOR APPLICANT TO FILL IN BUILDING tion department. ADDRESS `� (e-S- w C7 �n (/ //'� _/ (PRINT OR TYPE ONLY) fe "/-9� Applicant (�- LOCALITY ie NO. TYPE OF APPLIANCE OR EQUIPMENT FEE c� CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST LrU�' 64COMPENSATION INSURANCE CROSS ST. (This section need not be completed if the work involved by ABSORPTION UNIT, BTU----. DISTRICT NO. PROC ED 13 the permit is for one hundred dollars ($100) or less.) ;or I certify that in the performance of the work for'which this AIR HANDLING UNIT, CFM permit is issued, l shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws. BOILER, BTU APPROVALS DATE SPECTOR'S SIGNATURE Applicant COMPRESSOR, BTU QI `0t�� ff O ROUGH Date 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 COOLERVALID with comply with such provisions or this permit shall be deem- ed revoked. FURNACE: FAU GRAVITY n n / LICENSED CONTRACTORS DECLARATION FLOOR BTU �2� v I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT— J (commencing with Section 7000)of Division 3 of the Business WALL. and Professions Code,and my license is in full force and effect. } License Number V037(31 Lic. Class Loa , CL Contractor w// '�� L `NAJ E 1 Da� y-30_�` ❑ I am exempt under Sec. B.&P.C. for this reason. Plan check fee y Date: PERMIT ISSUING FEE $ 00 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 , �;_ 01; Professions Code): 1-t°} ❑ I, as owner of the property, or my employees with ADDRESS 1 IsC.i?S wages as their sole compensation, will do the work and the structure is not intended or offered for sale (Section CITY TEL. NO. T l.!#AL 25 = 00 7044, Business and Professions Code). OWNER 2 Aa� ; �;v 215.01. ❑ I, as owner of the property, am exclusively contracting /" with licensed contractors to construct the project (Sec- MAIL rr CHANGE tion 7044, Business and Professions Code). ADDRESS d J `� !JN 9� _• 1i 4 °`-•J CONSTRUCTION LENDING AGENCY CITY Tf-KL ��, �! TEL. NO. '�O C) 80 I hereby affirm that there is a construction lending agency for ._ the performance of the work for which this permit is issued CONTRACTOR Vi1rt/tj`I (Sec. 3097, Civ. C.). ('.E i }� ADDRESS G / s t At i 1 °19 Lender's Name yL y Lender's Address CITY 7P/k !K ("� TEL. NO.STATE LIC. C, I certify that I have read this application and state that the CENSE NO. y6 ,J„j CLASS fCd D 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 �upo the above-mentioned property for inspection purposes. i�J� f' �` �D SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent �f Date ©s &O PA) 0aL /VL mar,1e9 Y7 VC_