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HomeMy Public PortalAbout5420 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 ' pr a c6t"ied copy thereof (Sec. 3800, Lab. C.) 76A364C - 20-0046 DPW 9/88 .Policy Ido. Company � 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 r AI �/..-.,j/�� tion depcirtment. ADDRESS O l iv�•I / v (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. PRO ssED BY the,permit is for,one hundred dollars ($100) or less.) a /J r AIR HANDLING UNIT, CFM f/V _'r✓ I certify that in the performance of the work for which this0 permit,is issued, I shall not employ any person in any manner . so as to become subject to the Wor:keCompens tion Laws. BOILER, BTU APPROVALS DATE INSPECTOR'S SIGNATURE e� COMPRESSOR, BTU D ROUGH Date 1 Applicant NOTICE TO APPLICANT: If, after mak g' this Cer cote of VENTILATION SYSTEM FINAL �J 2 7 Exemption, you, should become subject to th Workers' Compensation provisions of the Labor Code,'you must forth- EVAPORATIVE COOLER VALIDATION with comply.with such provisions or this permit shall be deem- ed revoked. FURNACE: FAU RAVITY 00 LICENSED CONTRACTORS DECLARATION- FLOOR BTU I hereby affirm that'l 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. T4�T } License Number 9 Lic. Class Z Q17 50 oil. O Contracto V'p. ; 7 ~' U r Date � ❑ I am exempt under Sec, 0 Plan check fee u, B:BP.C. for this reason. H PERMIT ISSUING FEE $ Z Signature Date: _ 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): '-T F1ADDRESS I, as owner of the property, or my employees with 0 �G wages as their sole compensation, will do the work and ACC °g the structure is not intended or offered for sale(Section CITY G717yTEL. NO, 7044, Business and Professions Code). 307 OWNER I, as owner of the.property, am exclusively contracting 1 ITEM with licensed contractors to construct the project (Sec- MAIL tion 7044, Business and Professions Code). ADDRESS 49 - 00 CONSTRUCTION LENDING AGENCY CITY TEL. NO. i I��L I hereby affirm that there is a construction lending agency for CHECK 48°00 the performance of the work for which this permit is issued CONTRACTOR , (Sec. 3097, Civ. C.). CHA 3E .00 ADDRESS Lender's Name �p �y CITY TEL. NO. Lender's Address 0000-0001 9/20/89 i t 1 certify that I have.read this application and state that the STATE LIC. LICENSE NO. CLASS �}V iV 1 A}'i oyC, above information is correct. ]'agree to comply with all County ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter upo the a ove entioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE g-2o-may Signatur f Applicant o gent Date ©s