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HomeMy Public PortalAbout5750 ALESSANDRO AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers' Compensation Insurance, I HEATING - VENTILATING - AIR CONDITIONING ce?tifkd copy thereof (Sec. 3800, Lab. C.) 76A364C AW C C_ r b 29 a 0 20-0046 DPW 9/88 cy No. Company _o P r.'o "` (flcx:�.h ry a y ❑ Certified copy is hereby furnished.4 COUNTY OF LOS ANGELES BUILDING AND SAFETY 211 Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING _ tion department. ADDRESS J 7 O ' P V v A� j/�, >> )) (PRINT OR TYPE ONLY) Date-/—/— Jo Applicant (5 c,N e V Srs tea / NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITYT`e M �C �'•Y CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. v e Oa ABSORPTION UNIT, BTU •(This section need not be completed If the work'involved by DISTRICT NO. PRO SED BY the perperformance is for onehundred dollars ($100) or less.) �� (/ /)n I certifythat in the of the work for which this AIR HANDLING UNIT, CFM Jv( 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 INSPECTOR'S SIGNATURE Date Applicant COMPRESSOR, BTU y ROUGH NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL 1 Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VX ID 10 with comply with such provisions or this permit shall be deem- ed revoked. FURNACE: FAU GFAV Y LICENSED CONTRACTORS DECLARATION FLOOR BTU :5 -N W I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT— (commencing with Section 7000)of Division 3 of the Business HEATER: WALL and Professions Code,and my license is in full force and effect. ` �5 License Number 1 5-7- e•2 G Lic. Class C-4- 2- » ! / , a. V 6-a Contractor�kG �e J SaI&-,Iftf, Com— 30—91 ❑ DC I am exempt under Sec. O Plan check fee B.&P.C. for this reason. H Date: PERMIT ISSUING FEE $ Z Signature I 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): ?s I, as owner of the property, or my employees with ADDRESS y wages as their sole compensation, will do the work and ACCT. .T the structure is not intended or offered for saleSection CITY TEL. NO. tr 7044, Business and Professions Code). ( 3315 17 ''�''t)� OWNER F1 I, as owner of the property, am exclusively,contracting e b 1 ITEMS with licensed contractors to construct the project (Sec- MAIL i 1 �. Tion 7044, Business and Professions Code). ADDRESS `� J'O ,3 Q•ro ✓`O Ave TOTAL'I AL' 4 - _s0 CONSTRUCTION LENDING AGENCY CITYt,� TEL. NO. l �3 CHECK 24.50I hereby affirm that there is a construction lending agency for b the performance of the work for which this permit is issued CONTRACTORry e a a B 1 r� Pool ,Isi,3 (Sec. 3097, Civ. C.). �p ADDRESS O Sc, o S P Y�vt PG ��s _ Lender's Name / / (�'C�t- r�i� # q, CITY `7 S C4 ,- TEL. NO.6 U c� �IVLII.i—SJll1 1i/17t£rf. Lender's Address 56 1 certify that I have read this application and state that the STATE CLASLICS }j► i �`( _ LICENSE NO. � ' —G� '� CLASS above information is correct. I agree to comply with all County ordinances and State laws relating to building construction, C`1 and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date ©s