HomeMy Public PortalAbout9342 BLACKLEY ST_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT
' Z hereby affirm that I have a certificate of consent to self
insure, or-a certificate of,Wprke,Ad�Compeasotion-•Insurance,
or 6certified copy thereor(Sec. 800, Lab. C.) 76a364c ' HEATING - VENTILATING - AIR CONDITIONING
4 20-01'146 DPP 9/88
Policy No. Company
F] Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building❑ inspec BUILDING � f
tion department. /FOR APPLICANT TO FILL IN ADDRESS
(PRINT OR TYPE ONLY)
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST 1
COMPENSATION INSURANCE ` CROSS ST. ,LJ
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PRO ED 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 not employ any person in any manner 0
so as to become subject to the Workers' Compensation Laws. BOILER, BTU pA� APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant
COMPRESSOR, BTU Va� bb ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL 01�
Exemption, you should become subject to the Workers' r 3_-
IF��d
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER Ti
with comp)y with such provisions or this permit shall be deem-
ed revoked. FURNACE: FAU GITY
LICENSED CONTRACTORS DECLARATION 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.
License Number Lic. Class (� , d
O
.0
Contractor Date pe
❑ I am exempt under Sec. 0
Plan check fee U
B.&P.C. for this reason W
a
PERMIT ISSUING FEE $ 00vs
Date: z
Signature TOTAL FEE 0
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 ,
Pr essions Code):
I, as owner of the property, or my employees with ADDRESS _
wages as their sole compensation,will do the work and CITY TEL. NO. n.=• e
the structure is not intended or offered for sale(Section
7044, Business and Professions Code). y (3? '7.1111
' -
❑ OWNER �I, as owner of the property, am exclusively contracting 1 ''-t'CI',=
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS I-ITE m
CONSTRUCTION LENDING AGENCY CITY TEL. NO.
00
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.). !CHANGE .!.30
ADDRESS
Lender's Name
CITY TEL. NO. ;q "7 I
Lender's Address [)11It0�I—'0 ILs` r�/-:0 )�`L
I certify that I have read this application and state that the LICENSE NSTATE O. CLASS .4
11 IN + AM 9:1 i3
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize r presentatives of this County to enter
A;nt -ff�bb�;Opproperty for inspection purposes.
_ira rp � SEE REVERSE FOR EXPLANATORY LANGUAGE
ignature of Applicant or Agent Date Os