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HomeMy Public PortalAbout9321 BLACKLEY ST_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' Comrensation'Insurance, HEATING - VENTILATING - AIR CONDITIONING ' or a certified copy thereof,(Sec. 3800, Lab. C.) 76A364C 20-0046 DPW 9/88 Policy IN `� G Company /� � Certified copy is hereby furnished.. COUNTY OF LOS ANGELES BUILDING AND SAFETY n` Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING tion de artment. ADDRESS (PRINT OR TYPE ONLY) Date Applicant '�� �- i LOCALITY 9 -e -r NO. TYPE OF APPLIANCE OR EQUIPMENT FEE G CERTIFICATE OF EXEMPTION FROM WORKERS' I NEAREST COMPENSATION INSURANCE CROSS ST. (This section need not be completed if the work involved by ABSORPTION UNIT; BTU DISTRICT NO. PROCE ED 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 c./) permit is issued, I shall not employ any person,in any manner so as to'become'subject to the Workers' Compensation Laws. BOILER, BTU APPRovAisrE '_fyrtjbRt SIGNATURE Date Applicant COMPRESSOR, BTU ��7O ROUGH , NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL f, Exemption, you should become subject to the Workers' ' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER A ID TiIOM with comply with such provisions or this permit shall be deem- ed revoked. 1 FURNACE: FAU GRAVITY 0 1 1o LICENSED CONTRACTORS DECLARATION oL FLOOR BTU I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT— (commencing with Section 7000)of Division 3 of the Business WALL. and Professions Code,and my license is.in full force and effect. ) JAA _3 d01-4:Z—_T. 0T iC`�� ? v / tj } License Number Lic. Class , CL0 Contractor 4---Date C/4KZFpC ❑ I am exempt under Sec. Plan check fee W B.&P.C. for this reason. p, PERMIT ISSUING FEE $ v> Date: TOTAL FEE v Z Signature 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): v . I, as owner of The property, or my employees with ADDRESS wages as their sole compensation, will do the work and `' '' s 9 P t•t•_�.•€ a a the structure is not intended or offered for sale(Section CITY TEL. NO. _ 7044, Business and Professions Code). .41E,� ;85.0131 OWNER I,as owner of the property, am exclusively contracting a TTOM with licensed contractors to construct the project (Sec- MAIL s r ` �`- tion 7044, Business and Professions Code). ADDRESS TOTAL II AqL �� CONSTRUCTION LENDING AGENCY ''-- m CITY TEL. NO. I hereby affirm that there is'a construction lending agency for 'CHECK the performance of the work for which this permit is issued CONTRACTORL /N� , (Sec. 3097, Civ. C.). °�iHrr3E ,I;I� ADDRESS r/a�y/� dj/ Lender's Name -�� 7 ��''rv� �y � ��/� CITY_5'y Cp_'/C /L!�0/V 4 TEL. NO. 130,90`JO' I _E ` y 4` i STATELender's Address c,� / 5 �/'L I certify that I have read this application and state that the LICENSE NO. S v 3 CLASS C,-c5 J 1-) -I� i A}9 7:74 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 County to enter upon the above-mentione roperty for inspectio purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent D e - ©s