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HomeMy Public PortalAbout9144 EMPEROR AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT •1 hereby affirm that'I have a certificate of congent to self insure, or a.certificote of Workers' CoWpensati4n-Insurance, or a-certified copy thereof (Sec..'3800, Lab. C.) 76A364C HEATING - VENTILATING - AIR CONDITIONING 20-0046 DPW 9/88 PCIiGy1No. Company F-1 Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY ❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING 9 ` 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. (This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCEED BY the permit is'for one hundred dollars (3100) or less.) / AIR HANDLING UNIT, CFM I certify that in the performance of the work for which This 9�,. permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation_Laws. BOILER, BTU APPROVALS ATE PECTOR'S SIG TURE Dave Applica(V?ko� v� 7 COMPRESSOR, BTU �v 0 ROUGH NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL / Exemption, you should. become subject to the Workers' t},,,, Compensation provisions of the Labor Code, you must forth- ' EVAPORATIVE COOLER VALIDAT16N with comply with such provisions or this permit shall be deem-. ed revoked. FURNACE: FAU G, IT !e LICENSED CONTRACTORS DECLARATION FLOOR BTU Qt I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT (commencing with Section 7000)of Division 3 of the Business WALL and Professions Code,and my license is in full force and effect. Y- License Number Lic. Class , CL O U Contractor .Date 4C ❑ :I am exempt under Sec. Plan check fee � B.&P.C. for this reason. Date: PERMIT ISSUING FEE $ � Signature TOTAL FEE13 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 Ell Professions Code): I, as owner of the property, or my employees with ADDRESS ❑ ACCT. a wages as their sole compensation,will do the work and the structure is not intended or offered for sale(Section CITY TEL. NO. 3Ye"- f i 7044, Business and Professions Code). .1 ❑ I, as owner of the property, am exclusively contracting OWNER with licensed contractors to construct the project (Sec- MAIL )i_I)AL 37 - 00 tion 7044, Business and Professions Code). ADDRESS _ _-•„ CONSTRUCTION LENDING AGENCY CITY TEL. N 1� CHECK .'r'��_ I hereby affirm that there is a construction lending agency for " ti_jsg� aj 4?3 the performance of the work for which this permit is issued CONTRACTOR , (Sec. 3097, Civ. C.). ADDRESS Lender's Name CIT ! O ✓D f 100 01 011.301 i/ c j y, ' 9TEL. Lender's Address 8766 1 AM 8=a{ I certifythat I have read this application and state that the STATE LIC. - above PP LICENSE NO �1� CLASS G l� above 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 pont above-menf'oged p operty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date ' ©s