HomeMy Public PortalAbout10538 DANBURY ST_Mechanical_7/11/1989_furnance �. WORKERS'COMPENSATION DECLARATION APPLICATION p p pp l� 1�
4-'�hhere6y affirm that I have a certificate of consent to self A PLICATION FOR PERMIT '
insure, or a certificate of Workers' Compensation Insurance,. ]6A3 4C HEATING' = VENTILATING - AIR CONDITIONING
or a certified caF�j tthheerr/eof (Sec. 3800, Lab. C.) CE- IB EV, I0/81) -
A❑-1 Certified
LyLJheCompa Qr1%/ COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copyis hereby furnished.
�erti ted c py is filed with the county buil g inspec- FOR APPLICANT TO FILL IN BUILDING �( (
tion epo mens. (PRINT OR TYPE ONLY) ADDRESS
Date �� Applicant
LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CER FICATE OF EXEMPTION FROM WORKERS' NEAREST .?� 11��ZL
COMPENSATION INSURANCE CROSS
ST
.0 yc.
(This section need not,be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT No. J � / PROCESSED BY _
the permit is for one hundred dollars ($100)or less.) \ .
CFM `f
I certify that in the performance of the work for which this AIR HANDLING UNIT,
permit is issued, I sholknot employ any person in any manner
BOILER, BTU
so as to b/efome subject'to the Workers'
/Com((pC/5p�sation Laws. _ navaovgls onre INsv rows slcNnr e.
�z /% SAA .S .COMPRESSOR, BTU U6D o ROUGH
Date Applicant -r��!(�1�
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 must forth- EVAPORATIVE COOLER VALIDATI N
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU;GR�yJ�Y -
LICENSED CONTRACTORS DECLARATION .. FLOOR BTU 7-300-CEJ— �O ,
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, and my license is in full force and effect. Y
(�/y� d
License Number 27 1-886 Lic Class - D 0
Co•ntr MDO `7 YJ d' O
tracidvr �/C � /,����te
❑ I am exempt under Sec. - uVi
Plan check fee 0.
N
B.BP.C. for this reason'
Date: PERMIT ISSUING FEE $ Z
Signature TOTAL FEE ?Q
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License - D
Law for the following reason (Section 7031.5, Business and NAME
Professions Code):
❑ I, as owner of the property, or my employees with ADDRESS - ACCT.:
wages as their sole compensation,will do the work and
the structure is not intended or offered for sole(Section 'CITY TEL. NO. .,_ 3307 - 30.50
7044, Business and Professions Code).
El
1 ITEMS '
ElI, as owner of the property, am exclusively contracting OWNER
with licensed contractors to construct the project (Sec- MAIL n T ITAL 3. a-�Je0
Lion 7044, Business and Professions Code). ADDRESS /G
CONSTRUCTION LENDING AGENCY - CITY T NO. _ Q CHECK 30.50
1 hereby affirm that there is a construction lending agency'for _
the performance of the work for which this permit is issued- CONTRACTOR CHANGE .00
(Sec. 3097, Civ. C.). -
ADDRESS
Lenders Name 4� 0000-0001 7/11/89
CITY7z-m //. - TEL NO.�Q 1-)2 t
Lender's Address l•J �"��++ - 7
STATE - LIC. //�� //��7J{{ 4419 1 AM11:,,1
I certify that I have read this application and state that the - LICENSE NO. CLASS- (�.170 ; -- - -- - -- - -
above information is correct. I agree to comply with all County
ordinances and Statw*ws relating to building construction, -
opdt here y authoyy(zrte(Jepresentatives of this County to enter - -
( p nth bougie coned property for insp non urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of pplimn 1 l/