Loading...
HomeMy Public PortalAbout10714 ARROWOOD ST_Mechanical_6/9/1989_add new room WORKERS' COMPENSATION DECLARATION APP �raA��®�n koR PERN""' Ir L� lh I1 CJ ll- II�//Il f hereby affirm'that I have a certificate of consent to self. ; insure, o,Mb certificate,of Workers' Compensation Insurance; HEATING ��VENTILATING - A.IR ®N®B4Q®NING or @:certified copy}thereof (Sec. 3800 Lab: C.); 76A364HEATING 20- ` 0046 DPW 9%88 Policy No. Company 0. Certified copy., hereby furnj'shed COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified'copy is'filed*with the county building inspec- BUILDING' ❑ - S�-L^ tion department. FOR,APPLICANT TO FILL IN ADDRESS` NCY) r-� (PRINT OR TYPED Date Applicant LOCALITY - {' CERTIFICATE:OF EXEMPTION FROM WORKERS' NO, TYPE;OF.APPLIANCE OR EQUIPMENT , ' FEE NEAREST COMPENSATION,INSURANCE CROSS ST: ^�. Q w - -ABSORPTION UNIT, BTU '(Tl is section need not be completed if the Work involved by DISTRICT NO. PR CESSED BY the permit.is for one hundred dollars ($100)or less.) ='tl''certify that in the performance of the work for which this AIR HANDLING UNIT, CFM cy� ,permit iseis' ed; 'shalI not employ any person in any manner V BOILER,_BTU so as•to be ome subject,to the'Work ompe tl0 avJS. APPROVALS DATE NSPE TOR'S SIGNATURE Date Applicant COMPRESSOR 1 BTU ROUGH -� NOTICEAPPL CANT: If;: after making this.Certi rateof VENTILATION SYSTEM FINAL Exemption, ,you :.should .become 'subject',to the Workers': ' Compensation provisions of-the Labor Code; you must forth- EVAPORATIVE COOLER L1 ATION with comply,with•such provisions'.or this permit shall.be deem- ed revoked.. FURNACE: FAU GRAVITY tICEN$ED'CONTRAGTORS.DECLARATION.- FLOOR BTU= I hereby affirm that I am;licensed.under provisions of Chapter 9 HEATER: SUSPENDED UNIT_ (commencing•with Sec tion.,7000)of Division 3 of,the Business WALL. and_:,Professions.Code;and my license is in full-force and effect. ^ ' F� 9 ZS/� �. License Number Lic: Cl C. l�Y) c U 'T ° . Contractor gate 1 am exempt under�Sec f' Plan check fee v B.&P C. for this reason ✓ H p 'PERMIT ISSUING FEE $ Dater z Sig ature ;r TOTAL FEE. OWNER-BUILDER DECLARATION PLAN CHECK'APP LICANT I hereby affirm that I am exempt from the Contractor's License Law for the fall owing'reason ,(Section'7031.5,-Business and NAME Professions Code): evy ❑ 1,-as'owner of .therproperty, •'or'my employees with. ADDRESS wages as their sole Compensation,will do the'work and ACCT CITY ^ TEL. NO. °v the structure'is not intended or offered for stile(Section ' -?3 7044, Business and Professions Code)' �� �, OWNER � I, as owner of the property, am exclusively c'ont'racting ' - / d ITEMS. with"licensed contractors to•construct.:the 'project (Sec 1 MAIL �^ • tion.7044,.Business and Professions Code). ADDRESS ° r l�J yl���p ; CONSTRUCTION LENDING;AGENCY CITY TEL. N TOTAL ' I he affirm that there is a construction lend ing,agency.for L�' � � � °,} 25 tFie performance of the work for which this permit is issued CONTRACTOR (Sec:-3097, Civ. C.). D',.. CHANGEoQ[I r ADDRESS — Lender's Name ry.{y L 9/K STATE CITY �' TEL. NO. U1 iViJ-1 1 D/ .7!47 Lenderrs Address vakm, I certifythat I have-read this d lication and state that the••' STATE ,UC: 38p6�1 .p PP. LICENSE NO. �°Z .`JCJLTO I AM °e01 above information is correct. I agree to comply with all County' ; ordinances and;State laws relating To building construction, ' (Me eby auth repre entatives of this C unty to enter abov nt ned operty for inspe ion purposes. , SEE REVERSE FOR EXPLANATORY LANGUAGE Signature o Applicant or Agent Date ©,