HomeMy Public PortalAbout9159 BROADWAY_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' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof !Sec 3800, Lab. C.) 76A364C
1. - 'Q. . 20-0046 DPW 9/88 ,
Policy No. Company -
❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building inspec- BUILDING
tion department. FOR APPLICANT TO FILL IN BUILD" T`.
(PRINT OR TYPE ONLY) - / ��O�DvJ�
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENTFEE
• CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE , CROSS ST.
• ABSORPTION UNIT, BTU
(This section need not be completed if the work Involved by oistRicr No.' ��--77 PR s o BY
AIR HANDLING UNITCFM
»
r, the permit Is for one hundred dollars ($100) or less-) s O
I certify that in the performance of the work for which this ,
permit is issued, I shall not employ any person'in any manner -
so as to become subject to the_Workers Compensation Laws. BOILER, BTU APPROVALS DA INSPECTOR'S SIGNATURE
Dal
'a '' I > COMPRESSOR,'BTU �O - O ROUGH
NOTICE TO APPL CANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Lobar Code, you must forth- EVAPORATIVE COOLER. LIDA ION
_ with comply with such provisions or this permit shallbe deem-
ed revoked. _ _ FURNACE. ' -FALLAV17Y -- - - O
LICENSED CONTRACTORS DECLARATION FLOOR gTU -
1 hereby affirm that I am licensed under provisions of Chapter 9HEATER: 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.
, Icvas7 V
License Number v.I Lic. Clags2eb� a
.Contractor S I ff
D g
❑ I om'exempt under Sec.
Plan check fee -
B.BP.C. for this reason - W
O a
D te: PERMIT ISSUING FEES _ 2
Signature - TOTAL FEE (� -
OWNER-B LPE A ATI N PLAN CHECK APPLICANT -
Ihereby affirm that I am exempt from the Contractor's License D -
Law for the following reason (Section 7031.5, Business and NAME -
Professions Code): i
❑ I, as owner of the property, or my employees with ADDRESS"' - - -- Ar.0-t.T
wages as their sole compensation, will do the work and '-'
the structure is not intendedor,offered for sale(Seciioi CITY ---. . TEL. NO. 3307 J1.u0
7044, Business and Professions Code).
El 1,I, as owner of the property, am exclusively contracting - &:�'& TOTAL
ITEDS
with licensed contractors to construct the project (Sec- MAIL , ITL9t 1. 00
tion 7044, Business and Professions Code). ADDRESS Ii
- CONSTRUCTION LENDING AGENCY CITY TEL NO. CHECK _ 51.(hrl
I hereby affirm that there is a construction lending agency for r
the performance of the work for which this permit is issued CONTRACTOR D t.HANGE ,QI]
(Sec. 3097, Civ. C.). ,
ADDRESS
Lender's Nome / /�p � p�q - - -- 0000-000 1- 71 18i90
Lender's Address CITY • •1V'il TEL 1"7 1 AN 7:i 7
V i
certify that have read this application and state that the STATE - LIC � ^ -
Z
above information is correct. I agree to comply with all County LICENSE NO. CLASS GAN
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter '
upon the above-mentioned property for inspection purposes. '- - - - - -
SEE REVERSE FOR EXPLANATORY LANGUAGE F
Signale ( g Date