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HomeMy Public PortalAbout9189 JAYLEE DR_HVAC_5/7/1991_heater WOfiKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89 MAE n�E (�nI hereby affitm that.l have a-certificate of consent,to self insure, 76A36aCQp�p��p� p®� ®p G°pCG��ilp� U or a certificate of:Worker's Compensation Insurance, or a certified HEATING-VENTILATING -AIR CONDITIONING, J copy tftreot(Sec.3800 Lab.C.) Policy No. Company COUNTY OF LOS ANGELES* DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. ❑ Certified copy is hereby furnished. ❑ Certified copy is filed with the count building Inspection FOR APPLICANT-TO FILL IN_ BUILDING Y 9 ADDRESS department. - (PRINT OR TYPE ONLY) Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE" LOCALITY , CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. C.. t - - - - ABSORPTION.UNIT,BTU This section need.not be,com leted if the work involved b the ASSESSOR ©/_� ( - p Y - MAP BOOK PAGE PARCEL permit is for one hundred dollars($100)or less:) AIR HANDLING UNIT,CFM •- DISTRICT NO. PROCESSED BY I certify that in the performance of the work for which this permit is.is`sued, f shall not employ any person In any'manner so as to BOILER,BTU ✓ J ,' become subject to the Workers'Compensation'Laws. / i`l/ 1! tea✓ "1�� ��, COMPRESSOR,BTU Date Applicant VENTILATION SYSTEM APPROVALS DATE NSPECTOR'S SIGNATURE NOTICE TO APPLICANT: If, after making this Certificate of ROUGH Exemption,you should become subject to the Workers'Compensation r. EVAPORATIVE COOLER provisions of'the Labor Code, you must:fortfiwith'comply-with,such FINAL. 'provisions or.this permit shall be•deemed revoked. FURNACE: FAU GRAVITY' " CENSED CONTRACTORS DECLARATION f BTU VA ID LIT N Ithereby,affirm that 1 am licensed'un'der provisions of Chapter 9 SUSPENDED UNIT (commencing with Section.-7000) of Division 3 of the Business and HEATER: WALL • ' Professions Code,and my license is in full force and effect. Ge License Number tic.Class L Contractor Date V "' Plan check.fee I am exempt under Sec .- O B.&P.0 for this reason PERMIT ISSUING FEE$ Date: V TOTAL FEE Signature CO OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT Z '1 hereby affirm thatJ am'exempt from the Contractor's-License,Law NAME D =' Jor the following reason (Section 7031.5, Business and Professions _. s Code): fill i a B ADDRESS y I; as.owner of the..property, or my employees with wages as their sole compensation,=will do the work and the :CITY , TEL.NO. UJ structure is n'ot'intended or offered for sale(Section 7044, ' 1T1 Business and Professions Code). OWNER ❑ I, as owner of the.property, am exclusively contracting MAIL i— 2'5 - 00 with licensed contractors to construct the project (Sec- ADDRESS L i- tion 7044, Business and Professions Code). �— ' n CONSTRUCTION LENDING AGENCY CITY' TEL. /� I hereby affirm that there•.is a construction lending agency for CONTRACTOR the performance of the work for which this permit Is issued D (Sec.3097, Civ.C.). „ ADDRESSOF i'i3 i^&ESI. s l Lender's Name .. .. CITY" TEL.NO. � O ? fii t a i +} Lender's Address STATE 'LIG I certify that I.have read this application and state that the above LICENSE NO.• CLASS information is correct. I agree to comply with all County ordinances and State laws relating to building constqct' and hereby authorize repr ntatives of ount to en r upon the above-mentioned pr pe y for inspe n pure ses. SEE REVERSE FOR EXPLANATORY LANGUAGE NATURE OF ICANT OR AGENT _DATE - .