HomeMy Public PortalAbout9400 BROADWAY_Mechanical__ 'a• ' WORKERS' I hove
a serif DECLARATION APPLICATION
ION FOR PERMIT
1 hereby affirm that I have a certificate of consent to self � PY u �( R
insure, or a certificate of Workers' Compensation Insurance, 76A364C HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec. 3800, Lab. C,) -.
_ CE-818(REV. 10/81)
Policy No,.
Certified copy is hereby furnished., COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING Q y V _
tion deportment. (PRINT OR TYPE ONLY) ADDRESS _/ 7
Date—Applicant LOCALITY
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 DISTRICT NO. PROLE 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 - �c
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. BOILER, BTU APPROLI DATE�J INSP TOR'S SIGNAT RE
Dale�P if, aft COMPRESSOR. BTU ROUGH
NOTIC TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL - �-
Exem tion, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATI N
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU_GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9HEATER: SUSPENDED WALL UNIT_
'(commencing with Section 7000) of Division 3 of the Business - !/ }
and Professions Code,and my license is in full force and effect. y
O
License Number tic. Class D U
• OG
Contractor Date O
❑' I am exempt under Sec. W
Plan check fee . N
B.BP.C. for this reason' Z
Dofe:
PER ISSUING FEES -
'
Signature TOTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPUCAN
I hereby affirm that I am exempt from the Contractor's License D
Law for the following reason (Section 7031.5,Business and NAME
o esslons Code):
I, as owner of the property, or my employees with ADDRESS
as
as their sole compensation, will.do the work and -
the structure is not intended or offered for sale(Section CITY TEL. NO.
7044, Business and Professions Code). - -
El1, as owner of the property, am exclusively contracting OWNER
witH licensed contractors to construct the project (Sec- MAIL e 6 0 8 0 A
tion 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY .CITY - TECNO. /� �{,e e • • • 8
I hereby affirm that there is a construction lending agency for '
the performance of the work for which this permit is issued CONTRACTOR D ( • ° 2 0.50
(5ec. 3097, Civ. C.). - - _ _
ADDRESS _.. . . . .^ .. :r•e-e • 20.5 0"
Lender's Name 1298-8.6
CITY NO. __ _ _
lender's Address
STATE LIC.
1 certify that 1 have read this application and state that the LICENSE NO. CLASS
above information is correct. I agree to comply with all County
ordinances and State lows relating to building construction,
and hereby authorize representatives of this County to enter -
pon the above-m boned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applic n1 org n2 t D.16