HomeMy Public PortalAbout9955 DUFFY ST_Mechanical__ WORKERS' COMPENSATION DECLARATION n (�P(I C /�M N FOR n 2 np n/T
I hereby,affirm that I have a•certificate of consent to self G�11!" L� G=� I1V I1�C lr LSII�I1Vl1 Il
insure, ana certificate.af Workers Compensalian Insurance, HEATING _ VENTILATING . AIR CONDITIONING
or a certified copy thereof (Seo. 3800, Lab. C.) 76A364C ,
20-0046 DPW 9/88. '
Policy No. Company
❑ Certified copy.-is hereby furnished. s COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy.is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. ADDRESS '
• (PRINT OR TYPE ONLY)
Date Applicant ' LOCALITY
NO. TYPE'OF APPLIANCE OR EQUIPMENT, FEE
CERTIFICATE OF EXEMPTION FROM,WORKERS' NEAREST �� .•.�
COMPENSATION INSURANCE CROSS ST. w
(This section.need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO, PROCE BY
the permit is for one hundred dollars•($100) or,less.) %
I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM I/IJP
permit is issued, I shall not'erriploy any person in any manner v l�
50 a5 10 became subject 10 the Work rS;' BOILER, BTU
Pen5a110n LOWS. r y� APPROVALS DATE INSP TOR'$SIGNATURE
Q�����q-a�.�.QQ COMPRESSOR,BTU oOy IM) ROUGH
Date —Applicant �.
'NOTICE T APPLICANT: If, after Ing th 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 VA ID I N U
with comply with such provisions or this permit shall be deem-
ed•revoked. FURNACE: FAU GRAY Y ?l
LICENSED CONTRACTORS DECLARATION: FLOOR' BTU I �J l
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: : SUSPENDED UNIT—
(commencing'with Section 7000)of Division 3 of•tke Business WALL.
and Professions Code,and.my license is in full force and effect. DO ® r1 n
GTsyP t 5 CL
y
License Number 3 rZ Lic. Class C—ZO D
Contractor , t C4eV1fr Date f,E—1-2,0 V
❑ x6 exempt under Sec. O
Plan check fee - u
W
B:BP.C:for'this reason. H
Date: PERMIT ISSUING FEE,$ 4
Signature TOTAL FEE'
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that.l'am exempt from the Contractor's License D
Law for the-following reason.,(Section 703l..5, Business and NAME
Professions Code):
❑ I, as owner of the property, or-my employees with. ADDRESS f
wages as their sole compensation, will do the work and
the structure is not intended or offered for sale (Section CITY TEL..NO. A�••_.# o•'
7044, Business and Professions Code). /� i. <"�'f e-
OWNER; &7o JR5 MYi/� FeL�d�� ���. .t,„�_I
❑, 1„as owner of the property, am exclusively contracting i
with licensed contractors to construct the project (Sec MAIL. ITEMS
tion 7044, Business and Professions Code): ADDRESS• ��' ®�P"P�
CONSTRUCTION LENDING AGENCY r' .)O IAL 57.® 00
CITY ' e r�� TEL. NO.
I-hereby affirm that there is a construction lending agency for' , CHECK 51 9
the erformance.of the work for which this permit is issued � � `_ 'tt ,I}I'
P p CONTRACTOR 7 `.G� /f/e, �G D C
(Sec. 3097,;Civ. C.). t.�����
ADDRESS /C�e&A VIP
Lender's Name
CITY /LC/�7iGJ�� V/T• TEL. NO.
YV7k 00130-01t(3i f 3"1913 ji 3
Lender's Address ' ' 7 i.!
STATE LIC. /'
I certify that I' have read this application and state that the LICENSE•NO. CLASS (�`2-U 220 i �p}'; 7ai�,+
above information is,correct. I agree to comply with all County
ordinances and State laws relating to building construction, `
and 2th
authorize representatives'of this County to enter
u ove-mentio prop rty for inspection purposes. •
SEE REVERSE FOR EXPLANATORY LANGUAGE
Sianalure of Applicant or Age Date'