HomeMy Public PortalAbout9609 BROADWAY_Mechanical__ V
WORKERS' COMPENSATIDN DECLARATION
I`hereby offirm,that I have a certificate of consent to self APPLICATION FOR PERMIT
irsure, or a certificate of Workers' Compensation Insurance, ]6A364C HEATING - VENTILATING - AIR CONDITIONING J�
or a certified copy thereof (Sec. 3800, Lab. C.)
CIE-818(REV, 10/81)
Policy No. Company
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 - BUADDRESS
ILDING
tion department. (PRINT OR TYPE ONLY) bV ,fYY
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE SCJ
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. PROCESSED By,
the permit is for one hundred dollars($100)or less.)
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM �Lv
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 DATE INSG T SIGNATURE
DateApplicant COMPRESSOR, BTU 6� ROUGH r
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL �� .4"
Exemption, you should become subject to the Workers' .c —
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATId
with comply with such provisions or this permit shall be 43
deemed revoked. FURNACE: FAU—GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR
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 I ceeirsse is in full force and effect. `) C /J CL
O
License Number f 32T Lic. lassy20� V J v U
`4fi7 ShP1t� L a ► o
Contractor�� t H Uam exempt under Sec. Plan check fee d
81027A z
U
. 8.8P.C. for this reason PERMIT ISSUING FEE j �
Dote: " # o e 0,0 e a
TOTAL FEE
Signature ;I o e 41.00
OWNER-BUILDER DECLARATION PLAN.CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's Licensepool •e • e 4 1.0 0
Law for the following reason (Section 7031.5, Business and NAME o
Professions Code): t
ADDRESS ,I 0,2 8-88
I, as owner of the property, or my employees with
El
wages as their sole compensation, will do the work and CITY TEL NO.
the structure is not intended or offered for sale(Section
7044, Business and Professions Code).
OWNER
El v,
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL T
tion 7044, Business and Professions Code). ADDRESS Q y �1� .
CONSTRUCTION LENDING AGENCY CITY TEL. NO. -2p 21 hereby affirm that there is a construction lending agency for ).,/
the performance of the work for which this permit is issued CONTRACTOR It / < Q ��! pool(Sec. 3097, Civ. C.). ,
ADDRESS y'L o '\
Lender's Name
CITY f4004EL. NO. ve_
Lender's Address
006
STATE LIC.
I certify that I have read this application and stale that the LICENSE NO. CLASS ((�
above information is correct. I agree to comply with all County .
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
uponthe ov -me 'o d property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
L 0— 1I&C
Signi of Applicant orgent Date - _