HomeMy Public PortalAbout4934 ARDSLEY DR_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-004' P1N9/89 Q�p���Q��®� "�®� p����� GREEN
I hereby affirm that I have a certificate of consent to self insure, L��
or a certificate of;,Worker's Compensation.Insurance, or a certifiedHEATING-VENTILATING- IR CgNDITIONI
copy.thereof(,Sec.3800 Lab. C.)
'.
Policy No. Company` COUNTY OF LOS ANGELES 'DEPT OF PUBLIC WORKS: BUILDING AND SAFETY DIV
Certified copy is hereby furnished.
❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN q p ESS �"
department. (PRINT OR TYPE ONLY)
.Date - "Applicant N0.- TYPE OF APPLIANCE OR EQUIPMENT: FEE -
LOCALITY
CERTIFICATE OF EXEMPTION FROM'WORKERS' NEAREST' �^� /� �
COMPENSATION INSURANCE ABSORPTION UNIT,BTU CROSS ST.T (,� .l�;I W D.
This section need not be,completed if,the work involved b ASSESSOR
.( P Y the � � � '� MAP BOCK PAGE ^" PARCEL
permit is forone.hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
' DISTRICT NO. PROCESSED BY
certify.that in the peiformance'of the work for which this permit
is issued,.l shall not employ any person in"any manner so as to' # BOILER,BTU ?
becomesubject to the Workers' Compensation Laws:
COMPRESSOR,BTU -
APPROVALS DATEINSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM , ' ,�-•'•�
NOTICE TO'APPLICANT:'If, after making this Certificate of ROUGHZ
Exemption,you should become subject to the Workers'.Compensation' EVAPORATIVE COOLER
provisions of,the Labor Code, you must forthwith comply with such. FINAL _g' C167 Ll
.provisions or this permit shall be,deemed revoked. FURNACE: FAU' GRAVITY
LICENSED CONTRACTORS.DECLARATION. FLOOR BTU VALIDATION
I hereby affirm that l am licensed under provisions of Chapter 9 SUSPENDED UNIT`
(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL
Professions Code, and'my license is in,full force and effect. "
License Number - Llc.Class . - `
IL
tom/
Contractor -Date m V
❑. I am-exempt under Sec. Plats Check_fee
B.&P.C..for this reason PERMIT ISSUING FEE$ i,U
°Date: TOTAL FEE LU
Signature
PLAN CHECK APPLICANT f)
OWNER-BUILDER DECLARATION Z
I hereby affirm that I am exempt from the.Contractor's License Law ' NAME:
for the following reason (Section 7031.5, Business and Professions
r
Code): ADDRESS A= 2,
I, as owner of the property, or my employees with wage's
as their sole compensation, will do the work and the CITY 1 " 7EL.N0.
structure is not intended or offered for sale (Section 7044, r'' ,LL
Business and Professions Code).. y OWNER V "
❑' I, as•owner of the property, am exclusively contracting MAIL' _i_'?�€L "s
with_license&contractors to construct the project(Sec- ADDRESS AZ-
tion 7044, Business and Professions Code).
CITY TEL'.NO.
CONSTRUCTION LENDING AGENCY
hereby affirm that there is a construction lending agency for CONTRACTOR
the performance of the.work.for which this permit Is issued _
(Sec.3097,Civ.C,). D
ADDRESS
Lender's Name
CITY TEL.NO. _ _`i 3 , c_}�
Lender's Address STATE LIC.
I certify that I have read this application.and state that the above LICENSE NO. CLASS;
information is correct. I agree to comply.wifh 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
SIGNATURE 0F APIMCANT OR AGENT DATE -