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HomeMy Public PortalAbout10656pres ARROWOOD ST_Mechanical_4/26/1985_compressor, furnace * ,.,WORKERS'COMPENSATION DECLARATION APPn �aA�� N FOR 'PERN� t I he affirm that I have a certificate of consent to self LL (� IJ�J U' (nVf�O insure, or a certificate of Workers' Compensation Insurance,. ;6A364C IiEATIWG .- VE.NITILATING AIR CONDITIONING or a certified copy thereof.(Sec. 3800, Lab. C. • p�3� / CE-818'(REV. l0/81) -». Policy N -( Company �J 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. ADDRESS / 6.SFd rl-pL-0OO L112 �c i (PRINT OR TYPE ONLY) Date 7 V A licani Imo' A �`^— LOCALIT PP NO. TYPE OF APPLIANCE OR EQUIPMENT FEE �l't 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 the permit is for'ohe hundred dollars($100)or less.) "AIR HANDLING UNIT, CFM 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 I- APPROVALS DATE Ns TOR'S SIGNAT E o COMPRESSOR, BTU ` r © io / ROUGH f Date Applicant 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 rnust forth- EVAPORATIVE COOLER I ALIUATI N with 'comply with such provisions or this:permit shall be deemed revoked. FURNACE: FAU GR VITY LICENSED CONTRACTORS DECLARATION FLOOR —BTUJO I hereby affirm that I am-licensed under provisions of Chapter 9SUSPENDED UNIT WALL (commencing with Section HEATER:--'7000) of Division of the Business } and Professions Code,and my license is in full force and effect. License Number_2MW —Lic:.Class' a� DAl 9 3 3 A Contractor n'hOe�' 7�1��1`fE/�ieT � {j O # 6.0.0-0 0 g' _ P I am exempt under Sec. w Plan check fee 5 Q B.&P.C. for this reason PERAl11T ISSUING FEE $ 3 O,5 0 Date:.: 0 0 0 Signature TOTAL FEE OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT, Q 2 6—S 5 I hereby affirm that I am exempt from the Contractor's License D Law for the following reason (Section 7031.5, Business and NAM Professions Code): ❑' I, as owner of The property, or my employees with ADDRESS wages as their sole compensation,will do the work and CITY'- TE/L. NO: ) 6 the structure is not intended or offered for sale(Section 7044, Business and Professions Code).. J Mrs. �r S+ - C ❑. 1, as owner of the property, am exclusively contracting OWNER T 0/ `, fNS , with licensed contractors to construct the project (Sec- MAIL DbS� tion 7044, Business and Professions Code). ADDRESS CONSTRUCTION LENDING AGENCY CITY'.,I; rn "� TEL.-NO. I hereby affirm that there is a construction lending agency forD the performance of the work for which this permit is issued CONTRACTOR If L N (Sec. 3097, Civ. C.). ADDRESS- Lender's DDRESS Lender's Name CIT 1 TEL..NO. Lender's Address [ STATE LIC. I certify that I have read this application and state that,the LICENSE NO. CLASS �i O 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 Date