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Home My Public Portal About9154 EMPEROR AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT I hereby affirm that I have a certificate of consent to self insure', or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING or a certified copy thereof (Sec. 3800,'Lob. C.) 76A364C G�-cJZa7026 f� /)/ L 20-0046 DPW 9/88 Policy No. gny /17G(1U�01J&ee(I- ZV� �• Certifiedified co�jil'i�Purnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY I��/7I� Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING `� do dep rtment. ADDRESS (PRINT OR TYPE ONLY) Date Zt Applicant LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE /r7Yt�/ CERTI KATE OF EXEMPTI FROM WOR RS' NEAREST COMPENSATION INSURANCE CROSS ST. (This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PRO S D BY the permit is for one hundred dollars ($100) or less.) �r' h I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM permit is issued, I shall not employ any person in any manner BOILER, BTU so as to become subject to the Workers' Compensation Laws. APPROVALS DATE INSPECTOR'S SIGNATURE 00 Date Applicant COMPRESSOR, BTU "fir deo `� ROUGH 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 VAUIDn with comply with such provisions or this permit shall be deem- ed revoked. FURNACE: LICENSED CONTRACTORS DECLARATION FLOOR FAU BTU IOY� '� C 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. 42 JAN 1, ,� d ct e rS ay QO d License Number 22DI6 2 Lic. Class C20 , O Contractor O-,a - �a(ItD��C�I_n�ate u E] • I am exempt under Sec. 0 Plan check fee u W B.&P.C. for this reason. CL J�f vQ Date: PERMIT ISSUING FEE $ H Z Signature TOTAL FEE _ 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 Professions Code): ❑ I, as owner of the property, or my employees with ADDRESS s AUT.4 wages as their sole compensation, will do the work and - _+{y-' 6..1.,111 the structure is not intended or offered for sale(Section CITY TEL. NO. 3" ! 7044, Business and Professions Code). }�OWNER ITEMS /�/f �� ❑ I, as owner of the property, am exclusively contracting TOTAL 6 :1 with licensed contractors to construct the project (Sec- MAIL �*/`// ADDRESS CETion 7044, Business and Professions Code). "I.011 CONSTRUCTION LENDING AGENCYCITY s' C»(/J�(<C TEL. NO. a t�(I I hereby affirm that there is a construction lending agency for CHANGE the performance of the work for which this permit is issued • CONTRACTOR fiWb�.JUS CQ, , (Sec. 3097, Civ. C.). ADDRESS pS } 0000-0001 Lender's Name ?687 1 AMI 1.1c CITY Ct N� � TEL. NO.�63.- L�7 s Lender's Address I certifythat I have read this application and state that the STATE LIC. PP above information is correct. I agree to comply with all County LICENSE NO. CLASS 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. SEE REVERSE FOR EXPLANATORY LANGUAGE "/&24Z 2- i9ignature of App cant or Agent Date ©s