Loading...
HomeMy Public PortalAbout6023 CLOVERLY AVE_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, or a certified copy thereof (Sec.38 , Lab C ) 7766A364C PW 9/88 t J_ HEATING - VENTILATING - AIR CONDITIONING Polic oCompany Certified copy is hereby furnished r�v/ COUNTY OF LOS ANGELES BUILDING AND SAFETY ❑ Certified copy is filed with the county buiIdin inspec- FOR APPLICANT TO FILL IN BUILDING tion depart ent ADDRESS (PRINT OR TYPE ONLY) Date Apple i r INO TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY � CERTIFICATE OF EXEdIPTII FROM WORKERS NEAREST COMPENSATION INSURANCE I CROSS ST ' ABSORPTION UNIT BTU (This section need not be completed if the work involved by DISTRICT NO_ PROCESSED BY , the permit,is for one hundred dollars ($100) or less) f� AIR HANDLING UNIT CFM I certify that in the performance of the work for which This — permit is issued, I shall not employ any person in any manner --BOILER BTU so as to become subject to the Workers' Compensation Laws APPROVALS ATE INSPECTOR S SIGNATURE Gt - - a r Date�� / �� 0 Applicant DELIA ELiE e Y' Al e, COMPRESSOR* BTU- C2 ROUGH NOTICE TO APPLICANT If, after making this Certificate of VENTILATION SYSTEM FINAL Exemption, you should become subject to the Workers' 1 Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER V I D T with comply with such provisions or this permit shall be deem- ed revoked t FURNACE FAUXTY _ O f LICENSED CONTRACTORS DECLARATION FLOOR BTU 2y, O I hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED NI ` (commencing with Section 7000)tof Division 3 of the Business WALL and Professions Code,and my license is in full force +and �effect Jb O �LC/�A( J ys 60 Z �3 z OD } License Number 5' LIZ Class�lSL_ Po. a ContractorRAC.' QgPL�_,Q ate ❑ I am exempt under Sec Plan check fee W B&P C for.this reason Date PERMIT ISSUING FEE $ 3 p AICT.g H Signature TOTAL FEE q Q 310 97.1 OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I ITEMS I hereby affirm that I am exempt from the Contractor's License ,�! Law for the following reason (Section 7031 5, Business and NAME , TOTAL 97 . 00 Professions Code) ❑ j, as owner of the property, or my employees, with ADDRESS CHECK 97.00 - wages as their sole compensation,will do the work and - I (,}� .Ute the structure is not intended or offered for sale(Section CITY 4 TEL NO 7044, Business and Professions Code) I ` OWNER_ ❑ I, as owner of the property, am exclusively contracting R ��4 i 3/29/90 with licensed contractors to construct the project (Sec- MAIL tion 7044, Business and Professions Code) ADDRESS Q L�I/ 979.1 I AM i:E7 CONSTRUCTION LENDING AGENCY CITY /.-" , / TEL NO 71 t-p 111 I hereby affirm that there is a construction lending agency for - ""' Yt r ` oil the performance of the work for which this permit is issued CONTRACTOR FI (Sec 3097, Civ C ) ADDRESS P F'pV Lender s Name a CITY �y TEL NO33 i_ Lender's Address I certifythat'I have read this application and state that the STATE LIC - PP LICENSE NOCLASS L'- 0 L'^7 (0 above information is correct I agree to comply with all County J ordinances and State laws relating to building construction and hereby authorize representatives of this County to enter upon the above-me oned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE '3 o�gn..re Applicant or Agent Date, ' F ' , ©s