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HomeMy Public PortalAbout5148 BARELA AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION F®R PERMIT hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING or a certified copy thereof (Sec. 3800, Lab,. C.) /1�� 76A364C Policy N'l ) J�a� ompanyT�rxc± C, lTt7►4'L0 rhJyf�20-0046 DPW 9/88 De r p Ceed 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 ter department. ADDRESS 5-1 tich (PRINT OR TYPE ONLY) Date—.` Applicant 1 f 1 LOCALITY ; �� �' • Q f 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. PROC D 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 r 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 NSPECTOR'S SIGNATURE Date Applicant COMPRESSOR, BTU 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 VA IIETA TION with comply with such provisions or this permit.shall be deem- ed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED U IT00 — (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 + 30'6 illf Lic. Class C—";2 , 0 fdfContractor+pf-�, . 1(j J&,.�ted Date S 0 ❑ I am exempt under Sec. Plan check fee Lu B.&P.C. for this reason. H vF�� PERMIT ISSUING FEE $ Signature —„ ,,"w`"'" TOTAL FEE OWNE1661L Ek DECLARATION ��✓✓ PLAN CHECK APPLICANT I hereby atDrm`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 m employees with ADDRESS wages as their sole compensation,will do the work and HCCI a-' NO the structure is not intended or offered for sale(Section CITY TEL. . �1i1) 20.50 7044, Business and Professions Code). OWNER M ❑ I, as owner of the property, am exclusively contracting r 'G' j '�-� with licensed contractors to construct the project (Sec- MAIL tion 7044, Business and Professions Code). ADDRESS SII h CONSTRUCTION LENDING AGENCY CITY TEL. NO. I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued CONTRACTORCHANGEI -JVI (Sec. 3097, Civ. C.). r�—� `�i Z-c C ,i_,!_, ADDRESS 3®rD�=— A) I Lender's Name _ CITY ` a TEL. NO.� j�� $ ;?0i�11-00G E .1 6 t Lender's Address STATE LIC. !C£1 a a Cf a+' 1 certify that I have read this application and state that the LICENSE NO. 3 Fi CLASS �. =''s= '=° 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 Coun �o_enter upon the above- entioned prARpay- spection purposes. r- SEE REVERSE FOR EXPLANATORY LANGUAGE Siga¢ture # pplicant or Agent Date ©s