Loading...
HomeMy Public PortalAbout4947 ARDSLEY DR_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, _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) AbDRESS Date O fy Applicant �i�S�JJ� j � � 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. PROCESSED BY the permit is for one hundred dollars ($100)or less.)% I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM 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 Applicarit COMPRESSOR, BTU !9�11 �" ROUGH - NOTICE TO APPLICANT: If, after making this,Certificate of VENTILATION SYSTEM FINAL — Exemption, you should become subject to the Workers' I Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION 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 9HEATER: SUSPENDED UNIT(commencing with Section 7000) of Division 3 of the Business WALL and Professions Code,andmylicense is in full force and effect. License Number .�?J —140G Lic. Class A6 , U Contractor yF ICG/Z ❑ I am exempt under Sec. Plan check fee B.&P.C. for this reasonDate: � PERMIT ISSUING FEE $ 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): ❑ ADDRESS I, as owner of thePro property, or my employees with wages as their sole compensation, will do the work and CITY TEL.TEL. NO. °2 6 �1 6 A the structure is not intended or offered for sale(Section � _� r 7044, Business and Professions Code). OWNER O.� JJ/� // L7l7 # ° o 0 0 0 8 ❑ I, as owner of the property, am exclusively contracting I ' with licensed contractors to construct the project (Sec- 2 3 Q 5 0 tion 7044, Business and Professions Code). ADDRESS �/, /¢ 5 ° c- o,o CONSTRUCTION LENDING AGENCY CITY TEL. NO. �' "o,010 30506 I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued CONTRACTOR5 , 0;71 —8 4 (Sec. 3097, Civ. C.). ADDRESS Le'nder's Name 8 / Y— 'CITY TEL. NO3 •_S 0� 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 Signature of Applicant or Agent DSte