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HomeMy Public PortalAbout9650 CRAIGLEE ST_Mechanical__ WORKERS' COMPENSATION DECLARATION n NF C /,�MN POR nERNT I hereby affirm that I have a certificate'of.consent tri self �, G�llr LL lK1 IIV IT Ili 1!" UC%ll insure;(ora certificate of Worker.,' Compensation Insurance, HEATING . VENTILATING _ AIR CONDITIONING or a certified �-co y'thereof (Sec. 3800,'Lab:'Cr)' 76A364C ZZ90 20-0046 DPW 9/88 Pdlicy No. Company Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY. Certified,copy is filed with ihe.county building inspec- FOR APPLICAi�IT TO FILL II�1 BUILDING /7y /� tion department. ADDRESS 9�Xi' Q� e e� (PRINT OR-TYPE ONLY) �I� rnQ.l� � FG�11 5 . LOCALITY Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE , CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCECROSS ST. (This section need not-be completed if"work Pinvolve.d by ABSORPTION UNIT, BTU DISTRICT NO. PRO the 'P ermilt is for one hundred dollars.($100).or.less.) I certify that i_n the performance of,ihe work for which this AIR HANDLING UNIT, CFM 5"10 T} permii'is issued, I shall not employ any person in any manner L ' SO a5 f0 beCOmesubject 10 the,Workers' BOILER, BTU .Compensation Laws. � � APPROVALS DATE� I P TOR'S SIGNATURE COMPRESSOR, BTU ROUGH Date. Applicant NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL Exemption, ,you should _become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER. \, with comply with such provisions or this permit shall be deem- ed.revoked., FURNACE: FAU GRAVITY W� ` • LICENSED.CONTRACTORS DECLARATION FLOOR BTU tli I hereby affirm that 1 am licensed under provisions of'Chapter 9 HEATER: SUSPENDEDUNIT (commencing with Section 7000) of Division 3 of the Business WALL. and Professions Code,and my license is in,full force and effect.. 00 } License Number Lic. Class D d ' A -,.,Contractor y DV. K= O . I am exempt under`Sec.- E' I.- Plan check fee U B.&P.C. for'this redsori.' PERMIT ISSUING FEE $ 13 OQL Date: Vf ' Signature TOTAL FEE I 10U OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT ' I hereby affirm that I am'exempt,from the Contractor's License Law for the following reason (Section.7031.5, Business'and 'NAME D v Professions Code): ADDRESS-- .'owner of the property, or my employees with', ill{-CT.ir I, as wa es as their sole com ensation,will do the work and f thestructure is not intended or offered for sale(Section CITY - TEL. NO. [; a Business and Professions Code). . / {{ Ty �,y ❑ OWNER / ( l.' 1 iltln't I, as owner,of the property, am exclusively contracting with licensed contractors to construct the project (Sec- MAIL /� /�1 / TOTAL AL 19 ® 0.0 tion 7044, Business and Professions Code). ADDRESS.t7 L / (rhe CONSTRUCTION LENDING AGENCY // CHECK 19.Y CITY (� TEL. NO. - I hereby affirm that there-is a construction lending agency fori ' f� ,13 11 the performance of the work for which.'this permit is issued CONTRACTOR �� . (Sec. 3097, Civ. C.).' ADDRESS ,J i Lender's Name - � ., 000 "011lI1 `} i9/(.?Ll CITY NO. Lender's Address t ✓i/'1¢ 1�Tk 8a:l k "that l'have' read this a lication and state that the STATE E LIC. - I certifyPP LICENSE NO. ��rSjS,-,� CLASS � - above information is correct.)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. 1 / SEE REVERSE FOR EXPLANATORY LANGUAGE ignature of Applican o Agent Date _ ©s