HomeMy Public PortalAbout9474 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 off' Compensation Insurance, ' HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec 3800, Lab C ) 76A364C
20-0046 DPW 9/88
Pollcv ni,}�+' ' 'Company •• '•' •� - , _ _
r : - COUNTY OF LOS ANGELES rBUILDING AND SAFETY
FJ_ Certified copy,is hereby furnished
❑ Certified copy is'filed with' county•building mspec FOR APPLICANT TO FILL IN :BUILDING {�
tion department i ADDRESS L LG�
_ (PRINT.,OR TYPE ONLY)
Date Applicant LOCALITYFL---M L� C
i NO TYPE OF APPLIANCE OR EQUIPMENT FEE
- CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST - •
COMPENSATION INSURANCE CROSS ST
ABSORPTION UNIT, BTU DISTRICT NO PROCESSEY
(This section need not be completed if the WOrk•inVOIV@d by` "
the permit'is for one hundred dollars ($100) or less.)
I certthat in-the performance of the wU
ify
'Work for'which this ' AIR HANDLING'UNIT, CFM �t /
permit,is issued, I shall not-employ any person in any manner', IL
BOILER, BTU
' so as to be c a subject to the Workers'' •--mpensation Laws APPROVALS DATE I PECTOR'S SIGNATURE
1.
Date 9 -Applicant �` COMPRESSOR, BTU •�r0 a 00ROUGH
e P ,.NOTICE TO XPPLICANT If; after.fnaking this Certificate of VENTILATION SYSTEM FINA(-
Exemption, you- should-become subject to the Workers' '
Corn pensation;provisions,of the Labof Code, youtmust forth- EVAPORATIVE COOLER NA
with comply with such provisions or this permit shall be deem- ;
ed revoked FURNACE FAU RAVITY /�
'LICENSED CONTRACTORS DECLARATION -FLOOR •BTU � i U
I hereby affirm that Lam 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 ' O . _ 0
/ Da �' s
Contractor Date L,
I am exempt under Sec O
Plan check fee W
B&P C for this reason
Date' PERMIT ISSUING FEE $ D Z
TOTAL FEE
' • Signature -
OWNER-BUILDER DECLARATIOtV 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)
F-1 1, .as owner of the property, or;my employees with ADDRESS, " Y -t .
wages as their sole compensation, will do the•work andL•{•t o Y
CITY TEL NO c7
the structure is not intended or offered for sale(Section L: _t, .I 11
7044, Business and Professions Code) ���qq ITEMS
❑ OWNER 1 Yi�Tt3 '
I, as owner of the property, am exclusively contracting •
with licensed contractors to construct the project (Sec- ,MAIL _,* �-
tion 7044, Business and Professions Code) ADDRESS TCI AL -_97 ® 00
CONSTRUCTION LENDING AGENCY 4 CITY L �, TEL N G 10 L•I{Ei c'=ri-;
I her affirm that there is a construction lending agency for �( �
the performance of the,work for which this permit is issued CONTRACTOR liP�nG�J�G �� , CHARGE
(Sec 3097, Civ C ) _
ADDRESS _ei/
Lender's Name �� 1� _ _ --
CITY C - TEL NO2(?v j— I_IrJ —Q{ILJ t7I t, 3_4
Lender's Address
I certrf that I have read this application and state that the STATE LIC C�2 ` - '1 �7 1 �I�fi t
Y PP ILICEINSE-NO CLASS i. •
above information is correct I agree to comply with all County
ordinances and State jaws relating to building construction,
'and hereby orize representatives of this County to enter -
upon,the ove-mentioned roperty for pispeelion purposes,
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date
O