HomeMy Public PortalAbout10780 BLACKLEY ST_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
i_' I hereby tiff;gym that I have a certificate of consent to self '
'insu"e, or a certificate of Workers' Compensation Insurance, HEATING - VENTILATINGM - AIR CONDITIONING
or a certified copy thereof (Sec 3800, Lab C ) 76A364C
3112 S1 Tig �u / CE-818(REV 10/81)-
Policy
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Policy No. Company /J C /✓�1 ;
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 BUILDINGr �G /j4.
tion depar yA c 'T (PRINT OR TYPE ONLY) ADDRESS (V ,C
Date r Applicant It � LOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST ly
. COMPENSATION INSURANCE CROSS ST
(This section need not be completed if the work involved by ABSORPTION UNIT,•BTU DISTRICT NO (� PROCESSED Y
the permit is for one hundred dollars ($100)or less.) Y
CFM jJ
I certify that in the performance of the work for which this AIR HANDLING UNIT, �
permit is issued, I shall not employ any person in any manner
50 OS TO become subject to the Workers'CompensdtwBOILER, BTUn Laws. S7 '" APPROVALS DATE I EC R'S SIGNATURE
Date Applicant
COMPRESSOR, BTU v O 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 VALIDA
with comply with such provisions or this permit shall be
deemed revoked FURNACE FAUC' A( Y
LICENSED CONTRACTORS DECLARATION FLOOR
BTU—
LICENSED
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED—UNIT—
(commencing
USPENDED UNIT(commenting with Section 7000) of Division 3 of the BusinessWALL
and Professions Code,and my license is in full force and effect'
/<T--s o
License Number c Lic Class V
L �� _ 87 bc_,�
Contractor A1�—I Date O
F—
❑ I am exempt under Sec W
Plan check fee IL
B&P C for this reason PERMIT ISSUING FEE $ Z
Date
Signature TOTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT z 9 5 6 8 A
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031 5, Business and NAME , o o;0 0 0
Professions Code)- ,? 0 4
❑ I, as owner of the property, or my employees with ADDRESS 'o 0.0 4 8, Q Q�
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). Q .:Q 5_0 9 c 8 8
OWNER J�❑ 1 J�s I, as owner of the property, am exclusively contracting Q 1.10
with licensed contractors to construct the project (Sec- MAIL / �j`r� n
tion 7044, Business and Professions Code) ADDRESS ! 0 E. /`j 1, /Z
CONSTRUCTION LENDING AGENCY CITY' !� 14� TEL NO6 Plr
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTOR �� rQ ,
(Sec 3097, Civ C.)
ADDRESS b 30 S
Lender's.Name
CITY �V/-✓r0 V 1)A- EL NO 73,5_7
5�311
Lender's Address -
STATE —2 p LIC
I certify that I have read'this application and state that the LICENSE NO G��� p CLASS- �? v
above information is correct I agree to comply with all County
ordinances and State laws relating to building construction,
and her/by author' a representatives of this County to enter
upon a above entlone property-for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
nature o Applicant or Agent Date -