HomeMy Public PortalAbout9189 JAYLEE DR_HVAC_11/4/1994_furnace, in/outlets • WORKER'S COMPENSATION bECLARATION 20-0046 DPW 9/89 ��j� �(` �j �p 2 (�,� UAAE
/�7I��II hereby affirm that I have a certificate'of consent to self insure, 76A364C /r�111 Ir ���MQ II ��IIV ®� PLSRNT . ,(;(,-,REEN
or a certificate.of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR.CONDITIONING,,,
f\��il �CJ
copy thereof(Sec:3800 Lab. C,)
Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS. BUILDING AND'SAFETY.DIV.
❑ Certified copy is hereby furnished. .
,❑ - BUILDING
Certified copy is.filed with the county building inspection FOR APPLICANT TO FILL IN ADDRESS
departments (PRINT OR TYPE ONLY)'
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
LC
CROSS ST.'
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
This section need not be"com feted if.the work involved.b the ASSESSOR
( P Y - _ MAP.BOOK PAGE PARCEL O�v -
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
` DISTRICT NO. PROCESSED BY ,
I certify that.in the performance of the work for which this permit ((��
is issued I shall not employ any person in any manner so as to BOILER,BTU ®� C
become subject to the Workers' Compensation Laws. //-
COMPRESSOR,BTU 26T&6'
APPROVALS DATE INSPECTOR'S'SIGNATURE
Date • Applicant VENTILATION SYSTEM _
NOTICE TO APPLICANT:'.If, after making.this'Certificate of ROUGH'
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL 24
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION / FLOOR BTU �S VALIDAT ON
I,hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000).of Division 3 of the Business and HEATER: WALL Code, and my license is in full force and effect.
License Number Lich Class
Contractor Date Q
❑ I am exempt under Sec. Plan.Check fee V
BAP.C.for this reason PERMIT ISSUING FEE$ O
Date: TOTAL FEE 141W
Signature_ d
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT Y (n
Z
I hereby affirm that I am exempt from,the Contractor's License Law. NAME D fes'
for the following reason (Section 7031.5, Business and Professions ; fir -;OaLIf
ADDRESS rH°fr�taG 1• s{•t
I, as owner of the property, or my employees'with wages
as'their sale compensation, will do the work and the CITY TEL.NO. i flE+I+=
structure is not intended or offered-for sale (Section 7044, _
Business-and'Professions Code). OWNER !I `1' i I ='f'L 51Ile-
'
Cwe
I, as owner of the property, am exclusively contracting MAIL Q 3ry H➢i 1-e`ay?r:
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions.Code).
�� D
the-performance forance of the'work for which this permit Is issued
(Sec.3097,Civ:C.).
ADDRESS
Lender's'Name
CITY TEL.NO.
Lender's Address STATE LIC.
certify that I have read,this application and state that the above LICENSE NO. CLASS
information is correct. I agree to cojg ply with all County ordinances
and State laws relating to building struction,and hereby authorize
representatives of 's Co ty to a ter upon the above-mentioned
p rty for ins p i p pos SEE REVERSE FOR EXPLANATORY LANGUAGE
GNATURE F APPLICANT ORA NT — --DATE