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HomeMy Public PortalAbout5926ALESSANDRO AVE_Mechanical WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT t h - y gifirm that I have a certificate of consent to self ins„ e, or a certificate of Workers' Compensation Insurance, HEATING VENTILATING AIR CONDITIONING or a certified copy thereof (Sec. 3800, Lab. C. 76A364C �v� p //� fin �nSA /C�( E-818(REV. 10/81) policyNp, (J/ Com al: Q T� ❑ Certified copy is hereby furnished. �— COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING tion department. ADDRESS (PRINT OR TYPE ONLY) �� _ ��•) Date Applicant LOCALITY /q•/ NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE ABSORPTION UNIT, BTU CROSS ST. i/�/f . (This section need not be completed if the work involved by DISTRICT NOPROCESSED 8 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 SIGNATUR Applicant S COMPRESSOR, BTU "2U G� ROUGH Date 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 deemed revoked. FURNACE: FAU GRAVITY /��, LICENSED CONTRACTORS DECLARATION FLOOR BTU %9' 0 0 I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED-UNIT— (commencing USPENDEDUNIT(commencing with Section 7000) of Division 3 of the Business HEATER: WALL and Professions Code, and my license is in full force and effect. �7 �flc� c- as �3 ISL License Number Lic. Class OV 1lg,4T/� -��a7 c� k 7 ► o Contractor � Date 0 ❑ I am exempt under Sec. W Plan check fee H BAP.C. for this reason Date: Z PERMIT ISSUING FEE $ A) 6 Signature TOTAL FEE (p3 C 0 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 Professions Code): ❑ I, as owner of the property, or my employees with ADDRESS wages as their sole compensation, will do the work and the structure is not intended or offered for sale(Section CITY TEL. NO. 7044, Business and Professions Code). OWNER /J _\\ El 1, as owner of the property, am exclusively contracting /�e� � u6 ��N with licensed contractors to construct the project (Sec- MAIL y /J tion 7044, Business and Professions Code). ADDRESS 1 1U /V L(/� , CONSTRUCTION LENDING AGENCY CITY'P4S�D�� � TEL. NO. /7/_r�Ta�. 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.). n y �� Lender's Name ...+ �/� ADDRESS 19Z ©Al-- vJ CITY T TEL. NO. _/2/6 Lender's Address I certifythat I have read this application and state that the STATE LIC. PP LICENSE NO. 7 0 CLASS C above information is correct. I agree to comply with all County ordinances and State laws relating to building construction, and hereby authorize r esentatives of this County to enter upo abo e-menu d property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date