Loading...
HomeMy Public PortalAbout5306 ENCINITA 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 cer?ified'copy t ereof (Sec. 3800c Lab C. 76A364C Policy NA Company 3 UX J0 �X/ATL 20-0046 DPW 9/88 . ❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is filed with the county building inspec- BUILDIN0." FOR APPLICANT TO FILL INJ tion department. ycy�� (PRINT OR TYPE ONLY) ADDRESS Ne Date `2 /' Applicant "� LOCALITY r L1�1Ak6 / C.� NO. TYPE OF APPLIANCE OR EQUIPMENT FEE rX 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. PR SSED 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 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 DATE INSPECTOR'S SIGNATURE Date Applicant COMPRESSOR, BTU !k2-- 06/� 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 VAill with comply with such provisions or this permit shall be deem- ed revoked. FURNACE: FAU LICENSED CONTRACTORS DECLARATION FLOOR BTU j hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT (commencing with Section 7000)of Division 3 of the Business HEATER: WALL. and Professions Code,and my license is in full force and effect. J_ oV4�S RD U } License Number ss Lic. Class ��'�`V a Contractor Date 3`r / L 10. O U oC ❑ I am exempt under Sec. Plan check fee W B.&P.C. for this reason. PERMIT ISSUING FEE $ a H D e: Z Signature TOTAL FEE OWNER-BUILD E ARATIN 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 ❑ I, as owner of the property, or my employees with ADDRESS y wages as their sole compensation, will do the work and AC.CT`a CITY TEL. NO. �? 04"i the structure is not intended or offered for sale (Section =_74f 17 _, 7044, Business and Professions Code). OWNERI ❑ I, as owner of the property, am exclusively contracting 4 w D I I T E r with licensed contractors to construct the project (Sec- MAIL J ��� // ) ® ❑ tion 7044, Business and Professions Code). ADDRESS ? N , Cil z __3 7 CONSTRUCTION LENDING AGENCY CITY G' TEL. NO. ('Hcr r L-rli L'_•2 i •-S o • I hereby affirm that there is a construction lending agency for __ the performance of the work for which this permit is issued CONTRACTOR C_ . � L_• is 1, Ii! (Sec. 3097, Civ. C.). ADDRESSV B n 9/— Lender's Name v �ll"j}r,— fLl f�1i; j CITY U / /< TEL. NO Z 7 Lender's Address -+�- ;lir ,•23 I certify that I have read this application and state that the STATE LIC. %� Ilill��: LICENSE NO. �j CLASS above information is car ect. I agree to comply with all County ordinances and State ws'relating to building construction, and hereby authoriz epresentatives of this County to enter up he above-me on2j property for inspection p oses. SEE REVERSE FOR EXPLANATORY LANGUAGE 7- Sig azure of nt or Agent Date ©s