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HomeMy Public PortalAbout9327 BLACKLEY ST_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT ' I her Affirm that i have a'`certificate of consent to self. + ;insure,.or a certificate of Workers' Compensation Insurance, o`r 76A364C HEATING - VENTILATING.- AIR CONDITIONING a certified copy thereof (Sec. 3800, Lab. C.) . ° 20-0046 DPW 9/88 Policy No.�Companyt�P5. -_0 � ❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY ❑ Certified copy is filed with the county building inspec- BUILDING do department. FOR APPLICANT TO FILL IN ADDRESS 2� ' Date Applicant �V1'� ( 1L1 (PRINT OR TYPE ONLY) LOCALITY- U G.7 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 I DISTRICT NO. P CESSED 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 permit is issued; I shall riot employ any person in any manner BOILER, BTU so as to.become subject to the Workers' Compensation Laws. APPROVALS DATE NSPECTOR'S SIGNATURE G Date Applicant P150 A COMPRESSOR, BTU / Q 00 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 VALIDATIO with comp)y with such provisions or this permit shall be deem- �1 ed revoked. FURNACE: FAU LICENSED CONTRACTORS DECLARATION FLOOR BTU 41 CJV 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 licen a is in full force and effect. / >_ License Number Lic. Class -eZ a O 7 , Contractor &I r Date oC ❑ I am exempt under Sec. Plan check fee B.&P.C. for this reason. a Date: PERMIT ISSUING FEE $ Z Signature TOTAL FEE OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 5,D 1 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 j ❑ I, as owner of the property, or my employees with ADDRESS !� wages as their sole compensation,will do the work and �'C T°s CITY TEL. NO. the structure is not intended or offered for sale(Section 3307 55.00 7044, Business and Professions Code). OWNER I, as owner of the property, am exclusively contracting C�' 1 ITEMS with licensed contractors to construct the project (Sec- MAIL tion 7044, Business and Professions Code). ADDRESS TOTAL 5 ®00 CONSTRUCTION LENDING AGENCY CITY � TEL. NO. �_��.� 5.�c �f I hereby affirm that there is a construction lending agency for r ° ILI the performance of the work for which this permit is issued CONTRACTOR , ;HA °00 (Sec. 3097, Civ. C.). ADDRESS Lender's Name CITY'. TEL. NO. 0000-MOI 9/22/89' .Lender's Address STATE LIC. 55I certify that I have read this application and state that the LICENSE NO. CLASS 5� f4 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 above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of App icant or Agent T Date ©s