HomeMy Public PortalAbout9617 CRAIGLEE ST_Mechanical__ WORKER7
',S COMPENSATION DECLARATION PW 969 . �����
I h6A364C Qpp��CAT�®II�1FOR p
ereby affirm that'I fiave-a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING- AIR CONDITIONING
CCoOpy th reof(Sec. 3800 Lab.C.)
/pooCompa, COUNTY OF LOS ANGELES DEPT OF PUBLIC.WORKS BUILDING AND SAFETY DIV.'
❑ - Certified copy is hereby furnished.
❑ Certified copy is filed with the county building inspectionFOR APPLICANT TO FILL IN BUILDING
( �ADDRESS.
department. /+ (PRINT OR TYPE ONLY)
Date ( Applicant �' :L LOCALITY -7 �
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS.ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
This'section need not be'com feted if the work involved b the ASSESSOR
( P Y - MAP-BOOK �� PAGE�� PARCELQ�D
permit is for one hundred dollars($100)or less.) AIR.HANDLING UNIT,.CFM
- DISTRICT NO:' x PROCESSED BV ,
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'.Compensation Laws.
COMPRESSOR,BTU
- - .APPROVALS - DATE. INSPECTOR'S SIGNATURE ,
Date Applicant VENTILATION SYSTEM
NOTICE TO'APPLICANT: If, after. making this Certificate of ROUGH ,
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must.forthwith comply with such FINAL
provisions-or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION / FLOOR BTU VALIDATION'
I hereby affirm that 1. am licensed under provisions of Chapter 9 SUSPENDED UNIT 4r,;7-7 1L
(commencing with Sction 7000) of Division 3 of the Business and HEATER: WALL
Professions Code, and-my license is in'full force and effect.
License Number J Lic.Class
- ,.
t�-i 0
__.
Contractor -C""C "r/�`Date 'i __a
❑ .1 am exemprunder Set.
Plan checkfee _ '_•k� U
O
B.&P.C.for this reason PERMIT ISSUING FEE$ 110Zf
F-
: U
Date: TOTAL FEE Q W
Signature 1c l;i I a 1. =I�- _0)OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT f�j. . E', .3 Z
I hereby affirm that am exempt from the Contractor's License Law NAME D
for the following reason (Section 7031,5, Business and Professions
Code):
ADDRESS,:
❑ I, as owner of the property, or my employees with wages
as their sole.compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale (Section 7044, '
Business and Professions Code). WNER O \ t
❑ 1, as owner of the property;,am exclusively contracting' MAIL
with licensed'contractors.to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code). : . (y 1
CONSTRUCTION LENDING AGENCY CITY =-r C TEL.NO./D l
I hereby affirm.that there is a construction.lending agency for N7RACTOR �J D
I performance of•the work for which this permit Is issued ���
(Sec.3097,Civ. C.).
ADDRESS
Lender's Name _
CITY TEL.N . g_) �
���
L'ender's Address STATE LIC. - -
I certify that I have read-this application.and state that the above. LICENSE NO. CLASS
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 upon the above-mentioned
property for inspection'purp ses. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE O APPLICANTO ENT DATE