HomeMy Public PortalAbout5430 ENCINITA AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION
TION FOR PERMIT hereby affirm that hover cert Ci Compensation
consent to self P'i /'1 YV Y'( r IG Y'IIV�
insure, ti a certificateopthe of Workers' Compensation Insurance; 76A364C HEATING VENTILATING - AIR CONDITIONING
ora certified copy thereof (Sec. 3800, Lab..C.) -
. 20-0046 DPW 9/80
Policy No. - Company - COUNTY OF LOS ANGELES BUILDING AND SAFETY
.'❑ Certified copy is hereby furnished. -
Certified copy is filed with the.county building inspec- FQR APPLICANT TO FILL IN BUILDING
- tion epariment.
(PRINT OR TYPE ONLY) ADDRESS
'Datet 6 _ U Applic LOCALITY c-4 7-
NO. TYPE 05 APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF,EXEMPTION FROM WORKERS' - NEAREST /1
COMPENSATION INSURANCE CROSS ST.
(This section need not.be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PR ED By
the permit is forone hundred dollars ($100) or less.) /�
I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM " ) /7
permit is issued,I shall riot employ any person,in any manner ✓ sss/// -
so as to become subject to the Workers'Compensation Laws. BOILER, BTU //� APPROVALS DATE INSP CTOR'S SIG AIDRE
Date Applicant COMPRESSOR, BTU
—.;3f'-7! J/ / '- ROUGH t
NOTICEJO APPLICANT: If, after making this Certificate of , .. VENTILATION SYSTEM .. FINAL / 1
Exemption, you. should become subject to the Workers'
Compensation provisions of theYabor Code; you must forth- EVAPORATIVE COOLER V L16AT16N
withrcomply'withsuch provisions or this permit shall be deem-
ed revoked. - I FURNACE: FAU_GRAVITY
' t, LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby off irm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED—UNIT
(commencing
USPENDED UNIT(commencing with Section 7000)of Division 3 of the Business WALL
and Professions Code,and my license is in full force and effect.
T
License Numb/eri --L v 3 Lic. Class G`Z D O
Contra< OU���
tor_- v
f / L� o
nate
❑ I am'exempt under Sec. V
• Plan check fee W
- B.BP.C. for this reason' W
Date:
PERMIT ISSUING FEE ; d
Signature
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 ro ert or m employees with ADDRESS
❑ P P Y• Yt - ACCT
.i
wages ct their sole compensation;will f o the work and
the structure is not intended or offered for sale(Section CITY iEl. NO. - 3307 cc 00
7044, Business and Professions Code). I J '
❑ j, as owner of the property, am exclusively contracting OWNER D/�7 1 ITEMS
with licensed contractors to construct the project (Sec- MAIL
ADDRESS .�6D 0 0 Q�- D O 5t TOTAL aC a 00
tion 7044, Business and Professions Code). '
CONSTRUCTION LENDING AGENCY" CITY'. 3�N 4VfAj,-/F�TEL. NO.a}� a�7� - CHECK 556 011
I hereby affirm that there is a construction lending agency for --'-- -
the performance of the work for which this permit is issued CONTRACTOR7/� D CHANGE .010(Sec 3097, Civ. C.).
ADDRESS
Lender's Nome
CITY DN TEL. NO. ����� OCIOO-0001 1/ 9/90Lender's Address STATE LIC. "" 8141 -1 AN 9:25
I certify that I have read this application and state that the LICENSE NO. CLASS G� U
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
upon the above-mentioned property for inspection purposes. - -
�� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of App mnt or A nt 7 Date I Qs