HomeMy Public PortalAbout6022 AVON AVE_Mechanical_3/14/1990_furnance WORKERS COMPENSATION DECLARATION APPLICATION FOR PERMIT
hereby affirm that I have a certificate of consent to self I
Insure or a certificate of Workers Compensation Insurance 76A364C HEATING - VENTILATING - AIR CONDITIONING
or aicert,f,ed copy thereof (Sec 3800 ''Lab y�C ) I a t
Policy No vVD�Company e)")0 645- 20 0046 DPW 9/88,'
Certified copy 17 hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy ,s filed with the county building Inspec FOR APPLICANT TO FILL IN BUILDING
tion department Y ADDRESS 0Z Z v oAJ
(PRINT OR TYPE ONLY) ,
Er
Date _ 2' Applicant` LOCALITY'?
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPT1,01<1 FR9 WORKER NEAREST �/
COMPENSATIONINSURANCE CROSS ST p9 T/I')(/ (f�} .
ABSORPTION UNIT BTU
(This section need net u' comple the wool,Involved by DISTRICT NO PROCESSED
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 s
permit is Issued I shall not employ any person ,n any manner
so as to become subject to the Workers Compensation Laws BOILER BTU APPROVALS DATE INSPECTOR R'SIGNATURE
}
Date Applicant COMPRESSOR BTU - ROUGH
NOTICE TOIAPPLICANT If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption you should become subject to the Workers
Compensation provisions of the Labor Code you must forth EVAPORATIVE COOLER V ID T
with comply with such provisions or this permit shall be deem
ed revoked , FURNACE FAU G VITY ��}
LICENSED CONTRACTORS DECLARATION FLOOR BTU O V
I hereby affirm that I am licensed under provisions of Chapter 9 HEATERSUSPENDED UNIT-
(commencing with Section 7000)of Division 3 of the Business ' WALL
and Professions Code and my l icense,s,n full force and effect r
4 �-rG C/ T
License Number-�7 ` : $ Llc Class Z «g ® a
Contractor Date O
t ❑ , I aXexempf under Sec
Plan check fee W
B&P C for this reason H
Date PERMIT ISSUING FEE Z
t
Signature TOTAL FEE
1-1 ocl(jo
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) v '
F1 ADDRESS"^I as owner of the property or my employees with r f;tiwC� l T
■Y
wages as their sole compensation will do the work and
the structure is not,intended or offered for sale(Section CITY - .-. TEL NO 97 415.CO
7044 Business and Professions Code) OWNERG �EMi
❑ I as,owner of the property am exclusively contracting wt
with licensed contractors to construct the project (Sec � I�
tion 7044 Business and Professions Code) ADDRESS tTl (T1L _
00
CONSTRUCTION LENDING AGENCY CITY ` TEL NO i:HECV 2r-,■4�t
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTORAas O iCTL 11111ol CHANGE
(Sec 3097, Civ C )
Lender s Name ADDRESS € /2 t 1 }1 i r
CITYlynON CSV TEL NO L013i1-013131 `iI ilii IJ
Lender s Address 9506 1 Ahs 9,5
j certifythat I have read this application and state that the STATE { UC
PP LICENSE NO CLASS
above information Is correct I agree to comply with all County
ordinances and State jaws relating to building construction
and hereby authorize representatives of this County to enter
upon t�bove-me ned property ned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
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Sign re o A ,cant or nt Date Os