HomeMy Public PortalAbout9156 JAYLEE DR_HVAC_12/17/1991_furnace WORKER'S COMPENSATION DECLARATION iaA3a4C PW 9/89 /n�,—•rnl 11 ��N/n�'fir �®Ill I!-"®l!'ll Ir,LS W 111911�� �tr�
hereby affirm that I have,a-certificate of consent to self insure, �ilr�1 ll LIM
���or a cgtlficate of,Worker s,,Compensation Insurance, or a certified HE�ITII�IGVENTILATING -AIR CONDITIONING. ' E �J�J� �J
Copy thereof-(Sec.3800 Lab. C.)
Policy NoO 714'T Coinpany' S�i�►TL F4. COUNTY OF LOS�ANGELES DEPT 0E-PUBLIC WORKS, BUILDING AND SAFETY DIV.
. Certified copy is Hereby furnished:
Certified copy`is filed with the'county building inspection FOR APPLICANT TO FILL IN BUILDING `` __ vdeparture t; C�1 I.yrs c4m5T- eo (PRINT OR TYPE ONLY) ADDRESS
;
' Date Applicant (J , -*+ �++a NO. TYPE OF APPLIANCE OR EQUIPMENT FEE' LOCALITYv`�'�'
CERTIFICATE OF NEAREST EXEMPTION FROM WORKERS' CROSS ST.
COMPENSATION INSURANCE
ABSORPTION UNIT,BTU ASSESSOR //
(Tfils section need not'be completed if the work involved by the " 'MAP BOOK PAGEp/6. PARCEL:3,.
permit is;for one hundred dollars($100)or less.) _ AIR HANDLING UNIT,CFM -
I certify,that in the.`performance of.the work for which this permit "o. PROCESSED BY
DISTRICT
is issued, I shall,not employ'any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws. (/CJL �-�t��
COMPRESSOR,BTU' O �•
_ APPROVALS DATEINSPECTOR'S SIGNATURE -
Date Applicant VENTILATION SYSTEM )
NOTICE TO APPLICANT: If, after 'making this Certificate of ROUGH
Exemption,you should become subject to the Workers' Compensation EVAPORATIVE COOLER
provisions of.the Labor Code;-you must forthwith comply.with such FINAL
provisions or-this permit shall be deemed revoked: FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION �. FLOOR BTU Q® noa 3. VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED' UNIT'
(commencing with Section,7000) of Division 3 of the Business and . HEATER:
WALL
Professions Code, and mylicense)s in full force and effect:
License Number / F T' Lic.Class
Cr!'dD ws C` ., cd D o
Contractor dris+ '
Date
Plan check fee
❑ I am exempt under Sec: (p
e&P.0 for this reason PERMIT ISSUING FEE.$
Date:
U
, TOTAL'.FEE: _ .a
Signature,, co
PLAN CHECK APPLICANT
OWNER-BUILDER DECLARATION Z,
I hereby affirm that) am exempt from the Contractor's License Law NAME .
for the following reason (Section 7031.5, Business and'Professions D
Code):
ADDRESS
I; as.owner of the,property, or my employee's with wages
as their sole'compensation, will do the work and the CITY TEL.NO.., •. _ --• -•
structure Is not intended or offered for sale (Section 7044, °
Business and Professions Code). OWNER I sf ^
❑ I, as owner of the property, am exclusively contracting' MAILNL
i
with.licensed,contractors to construct the project (Sec- ADDRESS -, ��_ �(� i 3 L •_
tion 7044, Business and Professions Code). - ;1t
CONSTRUCTION LENDING AGENCY CI - �� TEL
I hereby affirm that there is a construction lending agency, for
the performance of the work for which this permit Is issued CONTRACTOR
(Sec.3097,Civ.C.). D
ADDRESS {
Lender's Name // .N `� A•Q�F3 �l I'943-637T
js t
CITY�7 TEL.NO. _.. •-
t',
Lender's Address STATE, LIC.
I certify that I have.read-this application and state that the above LICENSE NO. e CLASS L7
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 T
SIGNATURE OF APPLICANT OR.AGENT DATE