HomeMy Public PortalAbout9420 CAMINO REAL AVE_Mechanical__r
WORKRS' COMPENSATION DECLARATION APPLICATION FOR PERMIT
�l hereby affirm that'l have a certificate of consent to self
Insure, or 4kcertlflcatp of Workers' Compensation Insurance, HEATING - VENTILATING AIRCONDITIONING
orka. ,�Ifled copy thereof (Sec. 3800, Lab. a)
{ .240046 DPW9/BB
Pq ley No Company COUNTY OF LOS ANGELES BUILDING AND SAFETY
F-1Certifiedcopy Is hereby furnished.
❑ Certified copy Is filed with the county building Inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. ADDRESS /
(PRINT OR TYPE ONLY)
Date ApplicantLOCALITY
NO. TYPE Of APPLIANCE OR EQUIPMENT FEE
CERTIFICATE O� E)EMF`TION FROM WORKERS' NEAREST
COMPENSATION INSURANCECROSS ST.
(Thu sectlon rseed not be corttpleted if the work invoked by ABSN.ORPTIOUNIT, BTU �QQ asrufCr NO. BY
the ptrmIt Is for one hundred do 11. ($100).or less.) Inn11v'
I certify that In the performance of the work for which this AIR HANDLING UNIT, CFM
permit Is Issued, I shrill not employ any person In any manner
so as to become subject to the Workers' Compensation Laws. BOILER, BTU A??Rd✓us R's SFGt+r,TURE
Date AppllcanT COMPRESSOR, BTU ROUGH
ICE TO APPLICAf�{T
NOT • If, after making this Certlflcate of VENTILATION SYSTEM, FINAL ,s /
.Exemption, .you should become tubjed to the Workers
Compensation provisions of the Labor Code, you must forth- EIVAPORATTVE,GOOLER VALIDATION
with comply with such provisions or this permit;shall be deem-
ed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
r hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED UNIT—
(commencing with So,-Hon 7000)of Division 3 of the Business WALL
and Professlons Code,and my license Is In full force and effect.
CL
Ucense Number I Ic. Class • O
Contractor Data o[
❑ I am exempt under Sec 1 0
ri
Plan check fee LU
B.&P.C. for this.reasori N
PERMIT ISSUING FEE $ Z
TOTAL FEE
Signature
OWNER-BUILDER DECLARATION RAN CHECK APPLICANT
I hereby cr flrm that I am exempt from the Contractors License ,
Caw for the following reason �Sedlon 7031.5, Business and NAME
Profeeslons Code):
I, as owner of the property, or my employees with ADDRESS -
wages as their sole compensation,will do the work ffand �T.�-
the structure Is not Intended or offered for sale(Section' CITY TEL NO' ir C-7
704, Business and Professions Cod330757
Coded OWNER T
7 .00
❑ I, as owner of the property, am excluslyply contractlrt9 1 Ii'CEr-sra+
with licensed contractors to construct the project (Seo- MAIL ��??
tlon 704, Buslness and Professlons Code} ',DDR TOTAL 57 - CIO
CONSTRUCTION LENDING AGS- CITY TEL NO
I hereby cr flrm that there Is a corsiructlon lending agency for 57.00
the performance of the work for which this permit is Issued CONTRACTOR , # .00(Sec. 3097, Clv. C.}
NDDRESS _
Lender's Name i `
CITY + TEL NO. 0000--0001 71 18/90
Lenders Address
1 certify that I have read this application and state ,that the Licigm NO U� 1 1 Ah &:29
above Information Is corred. I agree to comply with all County .
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
--G-�8D
Slgrwtue OlApplicant or Agent Data