HomeMy Public PortalAbout10826 ARROWOOD ST_Mechanical__ WORKER'S COMPENSATION DECLARATION 200046 DPW 9/89 ���n �����®n„ FOR T
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14ereby afirm that I have a certificate of consent'to'self insure, II �(J,U/I)�or a,certificate of Worker's Compensation Insurance, or a certifiedHEATING-.VENTILATING-AIR CONDITIONINGt� uuu vuv uLLL���
copy thereof'(tec.3800 tab.C:)
Policy No./QJ'7 Company / COUNTY OF.LOS ANGELES, DEPT OF PUBLIC WORKS BUILDING AND SAFETY.DIV.
Certified copy is hereby furnished.
Certified co is filed with the county building inspAttion FOR APPLICANT TO FILL.IN gDDREss
de rtmen (PRINT OR TYPE ONLY)
Date Applicant LOCALITY R .
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE ..
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
ABSORPTION UNIT;BTU _ ASSESSOR '
(This section need not be completed if the work involved by the. MAP BOOK PAGE- PARCEL
„permit is for one hundred dollars($100)or less.)• •AIR'.HANDL'ING UNIT,.CFM DISTRICT NO. PROCESSED BV
- -
•
certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so,as to BOILER,BTU
become subject to"the Workers' Compensation'Laws.
COM PRESSOR,'IJTU
Date' Applicant / APPROVALS .DATE INSPECTOR'S SIGNATURE'
PP VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROU GH -
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith"comply with such' FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU' GRAVITY
LICENSED CONTRACTORS DECLARATION' FLOOR BTU VALIDATION
I hereby affirm that I am.licensed under provisions.of Chapter 9 SUSPENDED UNIT—,-
.HEATER: ®-�
-(commencing with Section 7000),of Division 3 of the Business and WALL
Professions Code,and my license is in full force and'eff(e�ct.
License Number �. 3Z ��
`L' Class
Class
•Contractor .`sem
�C k f't tiG Date 2-.1�_ 1 V
❑ +'.-.I`am exempt under Sec..
Plan check fee
B.BP.C:for this.reason• ' PERMIT ISSUING FEE,$ % U
Date:
-FT. FEE QO' 0-
Signature
Signature
PAN CHECK APPLICANT �.
OWNER-BUILDER DECLARATION r.
I hereby affitm'that I am exempt.from the Contractor's License Law NAME D for the following reason (Sect ioh'•7031.5, Business and Professions lr�t
Code) ADDRESS 'e' / f+f:: a g
D1, as.owner of the property, or my employees with wages f
as their sole compensation, will do the work•and the CITY C' �� TEL.NO. 7 f s% "' s 13"•.
structure is not intended or offered for sale (Section 7044,
Business and Professions Code). OWNER `
•' I-,.as owner of the property, am.exclusively contracting MAIL TO I i- 5-m.
with licensed contractors to construct the project (Sec- ADDRESS s
fai�'t s �j (_;Y a s IQ, ;
tion,.7044,Business and Professions Cod'e),
CITY -TEL.NO.
CONSTRUCTION LENDING AGENCY i Esr)�iG I f I
I hereby affirm that.there is a construction lending agency,for'. CONTRACTOR_ D
the performance of the•work for which this permit is:issued ,' ' .
(Sec �
.3097,Civ.C.). `
ADDRESS ( sslUl';Is €j=i i I .i y i.f'T
Lender's Name _
CITY., �I TEL.NO. l r F j. s tlT3 S c
Lender's Address y-
certify that I have read this application and state that the above. LICENSE NO.32 _5 CLASS-
information
ASS'information is correct:`1 agree to comply with all County'ordinances
and State laws relating to building construction,and hereby authorize
representatives of.thiS Kposes.
enter upon the above-m tioned
proper t on SEE AEVERSE'FOR EXPLANATORY LANGUAGE..
SIGNATURE OF A ANT OR AG TE - _