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HomeMy Public PortalAbout5025ALESSANDRO AVE_Mechanical WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT hereby affirm that I have r certificate of consent to self insure, or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING r a certified cop thereof (SGc. 3800, Lab. C. 76A364C / �` E� CE-818(REV. 10/81) Policy No. Company —�T�`f �G/dL'r�� " Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY In Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING tion department. ADDRESS q����� (PRINT OR TYPE ONLY) - Date ?l6— A licant //T3 LOCALITY pp NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. (This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY the 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'is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. BOILER, BTU APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant COMPRESSOR, BTU Qd L ROUGH 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 VALIDATION with comply 'with such provisions or this permit shall be L O deemed revoked. FURNACE: FAU GRAVITY © T LICENSED CONTRACTORS DECLARATION FLOOR BTU I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: 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. License Number./ /Oay Lic. Classes loop. U IIES Contractor r �� 0 C Date U ❑ I am exempt under Sec. U Plan check fee B.BP.C. for this reason' PERMIT ISSUING FEE $ 7_0 Date: e —Signature TOTAL FEE 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 / G Professions Code): �n v O 1_' G Q A El 1, `"13 I, as owner of the property, or my employees with• �.7 wages as their sole compensation, will do the work and a 1,a.Q the structure is not intended or offered for sale (Section CITY �� lI j;;- TEL. 7044, Business and Professions Code). o > o z 0.5 Q OWNER' ❑ I, as owner of the property, am exclusively contracting � v���� ^1 a �• Q, Q with licensed contractors to construct the project (Sec- MAIL ADDRESS �4�.5 ��s$� T. ' tion 7044, Business and Professions Code). '`� Q 6 F 1,1. CONSTRUCTION LENDING AGENCY CITY I hereby affirm that there is a construction lending agency for lL. J7EL. NO. the performance of the work for which this permit is issued CONTRACTOR (Sec. 3097, Civ. C'.). Pilo 'ADDRESS Lender's Name CITY TEL. NO. _ Lender's Address I certify that I have read this application and state that the LICENSE NO. 7'1V43-0 CLASS above 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- ntionedproperty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE . K Signature of Applicant or Agent Date