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HomeMy Public PortalAbout9974 BOGUE ST_Mechanical__ WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self APPLICATION FOR PERMIT insure, ora-cer ifiAte of Workers' Compensation Insurance, or a certir ed copythereoT�(Sec-3800, Lab. C )• 76A364C HEATING - VENTILATING - AIR CONDITIONING , N 20-0046 DPW 9/88 Policy No Company COUNTY OF LOS ANGELES BUILDING AND SAFETY ' Certified copy is hereby furnished. CO ' ❑ CeFiIfIed" copy,is filed with the county building inspec- •FOR APPLICANT TO FILL IN BUILDING tion department. ADDRESS �9-7 12).0 Go F_ (PRINT QR TYPE ONLY) Date Applicant Tam am �..� c4Tr NO TYPE OF APPLIANCE OR EQUIPMENT � FEE 6 6 CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCEABSORPTION UNIT, BTU p 4w%36 C CROSS ST �J - (This section need not be completed if the work involved by DISTRICT NO PRO E ED the permit is for one,hundred dollbFs (5100) or less.) I certify that m'the,performance of the work,for,which this AIR HANDLING UNIT, CFMI permit is issued, I shall not employ any person in any manner BOILER, BTU so as•to become subject to the Workers' Compens tion Laws. APPROVALS DATE NSPECTOR'S SIGNATURE Date ` _ `O Applicant COMPRESSOR, BTU ROUGH NOTICE TO APPLICANT: If, after making Certificate of VENTILATION SYSTEM. FINAL Exemption,' you should become-subject to the Workers' Compensation provisions of the Labor Code,•you must forth- EVAPORATIVE COOLER VALIDATION with comply with such provisions or this permit shall be deem- ed revoked.- FURNACE FAU GRAVITY =° LICENSED CONTRACTORS 4 DECLARATION FLOOR BTU 'I hereby dffiir that I ain licensed under provisions'of Chapter 9 HE -.SI SPENDED UNIT (commencing with'Section 7000)of Division 3 of the Business and Professions Code,and my license is in full force and effect. a License Number Lic. Class 03 T / , O Contractor Date CC ❑ I'am exmpt'under Sec ' ' 0 e Plan check fee B.BP.C. for this reason w_ N Date: PERMIT ISSUING FEE $ (� �; Z Signature TOTAL FEE d OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor's License pop.Law for the following reason,(I Section 7031.5, Business and NAME Professions Code)• ❑ .I, as owner of the property, or my employees .with ADDRESS,- wages as their sole compensation,will do the work andACCT.g the structure is not intended or offered for sale(Section CITY -- �_ TEL NO 7044, Business and Professions Code)' ❑ OWNER, .._ y contracting I„as owner of the property, am exclusivelI�� i=S with licensed contractors to construct the project (Sec- MAIL tion 7044, Business and Professions Code). ADDRESS CONSTRUCTION LENDING AGENCY) ��1Tr�L 0 CITY. TEL, NO I I hereby affirm that there is a construction lending agency for - CHECK 43.0 the performance of the work for which this permit is issued CONTRACTOR DonJG (:PJE- ,1?1- (Sec 3097, Civ. C.) CHANGE�.•����• Lender's Name I EA) ADDRESS f73> A-1 Alt 1 IT. �✓'� - . . .. Lender's Address— lZ�`T �D �T CITY' L-A- � TEL NO ct IZ GQ�� 011j�-01301 4/' +/911 STATE 1 //� / LICAM 7:25 j= I certify that I.have read this application and state that the LICENSE NO �V�� CLASS 1t4 1 nit �`'� above information is•correct. I agree to comply with all County , ordinances and State laws relating to building construction, and'he 'y authorize representatives of this County to enter u o e ove-meToned'property for inspection purposes. "•' - - •••• - ••• ' r (� ��✓ n M SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Appli nt or Agent Date j - ©s