HomeMy Public PortalAbout9450 BROADWAY_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION
PPLIC p TION FOR PERMIT
I hereby affirm that I have a certificate of consent to self PY IL Pi Ytl �H�
insure, or a certificate of Workers' Compensation Insurance, 76A364C - HEATING -"VENTILATING - AIR CONDITIONING
.or a certified copy thereof (Sec. 3800, Lab. C.)
•��� y yy
CE818(REV.10/81) - -
Polity No. hx�y ..�?{ompony !�/E
Certified copy is hereby furnished. - COUNTY OF.-LOS ANGELES , - ,BUILDING AND SAFETY
❑ -
- Certified copy is filed with thecouoty building.inspec- - FOR APPLICANT TO FILL IN BUILDING .�!\
tion (PRINT OR TYPE
department. ONLY)
ADDRESS
C9
P
p� ,
Dote��-/`'.. -�Applicant � NO. TYPEPF APPLIANCE OR EQUIPMENT � � FEE
LOCALITY
CERTIFICATE OF EXEMPTION FROM W E ' • . NEAREST
COMPENSATION INSURANCE CROSS ST.
(This section need not be completed if the work involved by - ABSORPTION UNIT, BTU DISTRICT NO. PROLES ev
the permit is for one hundred dollars ($100)or less.) - '
certify that in the performance of the work for which this AIR HANDLING UNIT, CFM _
permit is issued, I shall naFemploy any person-in any manner -
so as tobecome subject to the Workers'Compensation.Laws. BOILER, BTU _ APPROVAIS
DATE INSPECTOR'S SIGNATURE
Dote ApplicantCOMPRESSOR, BTU- ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of 'VENTILATION SYSTEM FINAL _Z t?d /� 1
Exemption, you should become subject to the Workers' _
Compensation provision4'af the labor Code, you must forth- EVAPORATIVE COOLER VALIDATION .
with comply with such provisions or this permit shall be
deemed revoked.- - FURNACE: FAU g9vITY _ ,
LICENSED CONTRACTORS DECLARATION FLOOR BTU O OG�V
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 t
�and effect.
-License Number%^ 9 yl. / Lic Class �+--`z - D V
Contractor�+✓CS/� / ,3, to'AI'L'S
❑ I am exempt under Sec: W
• Plan check fee IL
B.BP.C. for this reason' - W
— ' PERMIT ISSUING FEE $ Z
Date:
T - ,
Signature TOTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT -
' I hereby affirm that I am exempt from the Contractor's License D
Law for the following reason (Section 7031.5,Business and NAME ,
Professions Code): ' -
❑ 1, as owner of theproperty, or my-employees with ADDRESS '26 8'0,0 A
wages as their sole compensation,will do the work and
the structure is not intended or'offered for sale (Section CITY- - TEL. NO. #j e a . • e �,
7044, Business and Professions Code). - - - - -
' OWNER o,30,.50 '
❑ I, as owner of the property,.am exclusively contracting _ _
with licensed contractors tb construct the project (Sec- MAIL to,o a j n.5 G 6
' -tion'7044, Business and Professions Code). ADDRESS 1
CONSTRUCTION LENDING AGENCY CITY - - TEL No.
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.). - - - -
.. ADDRESS
Lender's Name _
CITU. ,. TEL NO. -
Lender's Address V
STATE /��7 p LIC.
I certify that I have read this application and state that the LICENSE NO. •�K7 J / CLASS
above information is correct. I agree to comply with all County,
ordinances and State laws relating to building construction,,
and hereby outhgrize representatives of this County:to enter - - --
upon tth��e,.,a�boyv(J/(fn property for inspection purposes, SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of App icon� Agent Date - '