HomeMy Public PortalAbout6042ALESSANDRO AVE_Mechanical WORKERS COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self
Insure or a certificate of Workers Compensation Insurance 76A364C HEATING --VENTILATING AIR CONDITIONING
or a certified copy thereof (Sec 3800 Lab C ) CE Bte(REV 10/81)
Pal cy No Company �_
❑
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 G /
NO TYPE OF APPLIANCE OR EQUIPMENT FEE C�
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST
COMPENSATION INSURANCE CROSS ST
ABSORPTION UNIT BTU
(This section need not be completed if the work involved by DISTRICT NOPROCESSED BY
the permit is for one hundred dollars ($100)or less )
I certify that in the performance of the work for which this AIR HANDLING UNIT CFM (J
permit is Issued I shall not employ any person in any manner BOILER BTU
so as to become subject to the Workers Compensation Laws APPROVALS DATE INSPECTOR S SIGNATURE
Dai ppllcani�� r� .� �� COMPRESSOR BTU ROUGHr yz,
NIE TO APPLICANT If after making this Certificate of VENTILATION SYSTEM FINAL -4,M .
Exemption you should become subject to the Workers ME F
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
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED—UNIT—
(commencing
USPENDED 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 Llc Class ► V
�C
Contractor Date 0
❑ I am exempt under Sec W
Plan check fee
B 8P C for this reason PERMIT ISSUING FEE $ a S v Y
Date
Signature TOTAL FEE 301so
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)
SS dN�t 1 0 7 0 A
tJh'q��
I as owner of the property or my employees with ADDREt
wages as their sole compensation will do the work and CITY TEL NO o o a o o 8
the structure is not intended or offered for sale(Section
7044 Business and Professions Code) OWNER i 2 0,- 3050
4 /�
El as owner of the property am exclusively contracting 3 0 +5 0�
ADD
with licensed contractors to construct the project (Sec MAI'RESS ` ,�s ���D o 0 0
tion 7044 Business and Professions Code) }
CONSTRUCTION LENDING AGENCY CITY �h ` TEL NO ; ���'�' 0508'—84
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 ) _
ADDRESS
Lenders Name
CITY i TEL NO
Lender s Address t
STATE LIC
I certify that I have read this application and state that the LICENSE NO CLASS _
above Information is correct I agree to comply with all County
ordinances and State jaws relating to building construction
and hereby authorize representatives of this County to enter
up,4ale above ent ne prop for Inspectionpurposes V ^
SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signature of Applicant or Agent !Date +