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HomeMy Public PortalAbout9117 EMPEROR AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 46DPW 9,69 76A364C APPLICATION FOR PERMIT LIME GREEN �• 76A3 I h'ere6y affirm that I have a certificate of consent to self insure, .t,or aicert ficate of Worker's Compensation Insurance, or a certified HEATING -VENTILATING-AIR CONDITIONING copy thereof[Sec.3800 Lab. C.) LI Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. ❑ Certified copy is hereby furnished. ❑J Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN ADILDING department. (PRINT OR TYPE ONLY) LOCALITY Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST CROSS COMPENSATION INSURANCE CROSS ST. © C �v ABSORPTION UNIT,BTU ASSESSOR (This section need not be completed if the work involved by the MAP BOOK PAGE PARCEL permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM D DISTRICT NO. PROCESSED BY 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 /� Q become subject to the Workers' Compensation Laws. 07 7v 0 COMPRESSOR,BTU x O 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'CompensationFINAL p EVAPORATIVE COOLER 0 s'' provisions of the Labor Code; you must forthwith comply with such �-- provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION• FLOOR BTU VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED—UNIT— (commencing USPENDED UNIT(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL Professions Code,and my license is in full force and effect. [ O g ou�-I .2d ed License Number Lic..Class 2 e ryl� CL Contractor Date 0 ❑ I am exempt under Sec. Plan Check fee O B.&P.C.for this reason PERMIT ISSUING FEE $ �C3 0"0 U Date: TOTAL FEE 8i DO d Signature CD OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT Z I hereby affirm that I am exempt from the Contractor's License Law NAME ''-11 for the following reason (Section 7031.5, Business and Professions — �~ L U-v dPe): ADDRESS JC' ��/ r.-. ; 1, as owner of the property, or my employees with wages � t '''`'I'°g C as their sole compensation, will do the work and the CITY `�( TEL.NO. 2 � structure is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER ❑ I, as owner of the property, am exclusively contracting MAIL 1-1 '� with licensed contractors to construct the project (Sec- ADDRESS TAP L tion 7044, Business and Professions Code). r e CITY TEL.NO. `=H'r'-='• CONSTRUCTION LENDING AGENCY t I herebyaffirm that there is a construction lendingagency for CHANGE ='tl' the erormance of.the work for which this perit s issuedCONTRACTOR ( ecp.3097,Civ. C.). ADDRESS Lender's Name, "�I_f CITY TEL.NO. ' . Lender's Address ., j i1 1'y STATE LIC. ��I- t 1 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 Cy purpos SEE REVERSE FOR EXPLANATORY LANGUAGE �o SIGWATURE OF APPLICANT OR AGENT DAT