HomeMy Public PortalAbout9549 BISBY ST_Mechanical__ LKERS'COMP`ENSATION DECLARATION APPLICATION FOR PERMIT
I.hereby affirm that I have a certtflcate of consent to self
Insure, ora
'certlflcate of Workers'Compensation Insurance, 9 HEATING -'VENTILATING - AIR CONbITIONFNG
or a certlfied copy thereof (Sec. 3800, Lob. C.) •. -,
CE-ere(REV. 10/61)
Policy No Company
Certlfled copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
n Cert(fled copy Is filed with the county bullding Inspec FOR APPLICANT TO FILL IN BUILDING r
T tion department.. ADDRESS / �✓��
- (PRINT OR TYPE ONLY)
Date Appllccm LOCALITY Tr�l
NO. TYPE OF APNIV4CE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WbRKERS' NEARESt
COMPENSATION INSURANCE CROSS.ST. e/f7) L Lr
(This sec?1on negd not be le ff.thi work•(mrolved by A$SORPTION UNIT, BTU o s1xxT rro. Y
the permM.Isfor'one hundr4d dollais ($100)'or leu.)
I certify:that In the performance of the work for which this A1R HANQUNGl1NIT, CFM /)
C/
permit Is(awed,f'ahall not employ any perwn In any manner BOILER, BTU,
2-6'03 to become subject to the Workers'Qompenzatlon. Arvrrovus oX,re s
Date D AT Ilcantr'41 s�� SSOR• BN _ ROUGH.
P
NOTICE.To APPLICANT:-If, after making this CeWfIcate of. VENF]LATIONSYSTEM ANAL �
Exemp(lon, you should become subject to `the Workers' _
CoMpensati6n provisions of the Lobor•Code,'you must forth-- EVAPORATIVE COOLER VALIDATI
with comply with such provlslonr or this permit shall be
deemed revokod. RJRNACE: FAU
LICENSED CONTRACTORS DECLARATION FLOOR BTl} W
I hereby afffFm that I amlicensed under provisions of,C hapten 9 HEAJIER: SUSPENDED UNt7 .
(c6mmendng With Section 7000) of Dlvlsion'3 of the Business WALL
and Professlora Code,and my Ilcensels'in full force and effect.
VLicense Number Llc.Oats _ _ _ _ - OC
O ,
Con trqctor Date F
a1 am eke,nipt under Sec. U
Prarl check fee
B.BP.C. for this reason PER MIT ISSUING PEE $
Date:
TOTAL FEE
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt ftom the ContractoP's Llcense :
Low for the:following reason (Section 7031.5, Business and NAME
fesslons Code):
I, as owner of the property, or my employees with ADDRESS T 1
wages os kelr.-sole compensation,will do the work and `.
CITY TEL
the structure Is Pot Intended or offered for sale(Section
7044,Buslneu and Professlons,Cbde). -
MAIL r!Jf�rt/ I ITE
I, as owner of the property, am exclusively contracting _
Tat-
with licensed contractors to construct the protect{Sec- '�'°ADORESS s�Y _ � �� 21T 34 _ 5_ 0
tion 7044, Builness and Ptofesslons Code). - �l
� �/ y r C
CONSTRUC11ON LENDING AGENCY L TEL NO.y_7-/ =y20Y c,� y. �go�/p d;o 4101Er % tir4.5(1 '
I hereby affirm that them ls'a construction Ignding agency for .��
the performance of The work for Which this permit Is Issued ��ACTOR - .
(Seca 3097, CIV.'C.).
ADDRESS, _
Lende's Name _ i'L 1 / 2/39
9TY TB- NO..
Lenders Addteu All 71149.
,.. STAYE UO
I certify that I have read this application and state that the DCENSE NO.. CLASS
above Information Is correct. I agree to.comply with all County
ordinances and State laws relating to building construction, r
and-hereby authorize representatives of this County to enter -
u n the e m nad property fpr-Inspection"purposes: . SEE REVE12SE FOR EXPLANATOky.LANGUAGE
51grwture of 4 1l.nt crAgent Dose