HomeMy Public PortalAbout5436 ENCINITA AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION A Im I�LBC p TON .'FOR PERMIT
I� IT
I hereby affirm that I have a gertificate.of consent to self P91r r t,1 A II�I Ir Y'l Ir IG tl'UNS Y .
insure, or a certificate of Workers' Compensation Insurance, 76A364C HEATING - VENTILATING AIR CONDITIONING
or a certified copy thereof (Sea. 3800, Lab. C:)
200046 DPW 9/88: '
Policy No. + Company
❑ Cernfied.copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING
yAND
/SAFETY
®., Certified copy is filed with the county building inspec- ' FOR APPLICANT TO FILL IN 8UILDIADDRE55 �.�{/C°A�!<
tion partm ent. (PRINT OR TYPE ONLY). /
Date Applicant - - - LOCALITY
NO, TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST �/ /
COMPENSATION INSURANCE CROSS ST. X (I A19'S
(This`sect ion need'not be completed If the work involved by ABSORPTION UNIT, BTU DISTRICT NO. / PR ED BY
' the permit is for one hundred dollars ($100) or less.) O"
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
50 OS t0'bECOTB Subject tO-the Workers Compensation Laws. BOILER, BTU / - APPROVALS DATE INSPECTOR'5 SIGNATURE '
COMPRESSOR, BTU F,
00
ROUGH n
Date ' Applicant -
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 V/Code, you must forth- EVAPORATIVE COOLER LIDAT N (�
with comply with such provisions or this.permit shall be deem-
ed revoked. FURNACE: FAU GRAVITY
- LICENSED CONTRACTORS DECLARAAOO
TION FLOOR BTU- -- -
hereby affirm that Iam'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,forc�e a�n)d effect. '
License Number `-"� �3 Lic. Class °� O �/ oTT D 0
j} L/ C'
Contract o ate t 6 0 ' - _ Im
'❑ , 1 am exempt under•Sec. - 0.
Plait check fee w
8.8P.C.'for this reason _ PERMIT ISSUING FEE $ 'U - un
Signature
Dote:
TOTAL FEE"
OWNER-BUILDER DECLARATION - PLAN CHECK APPLICANT -
I hereby affirm that I am exempt from.the Contractor's License D
Law for the following reason (Section 7031.5, Business and - NAME- • -
Professions Cade): - - -
a
" ❑
'I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and _
the structure is not intended or offered for sale (Section - CITY TEL. NO. 'FW7 - 55.00
704 Business and Professions Code)._ OWNER
I, as owner of the property, am exclusively contracting ,�..E��t 1 ITEMS
with'licensed contractors to construct the project (Sec- ADDRESS D -17 TOTAL 55 - 00
tion 7044, Business and Professions Code). - ,..
CONSTRUCTION LENDING AGENCY C 55 1 I,
CITY 7EL. No.� p :HECY, 7
- I hereby affirm that there is a construction lending agency for '�_�/o
the performance of the work for which this permit is issued CONTRACTOR '
'7 G f ���� D - CHANGE
(Sec. 3097, Civ. C.). -
- ADDRESS/ /�O� 41
Lender's Name CITY (��y TEL. INC.
Gy .L_ 9/90
V-
Lender's Address STATE1Hit 9e-1�
LIC. -• - C
I certify that I have read this application and state that the LICENSE NO. Sa CLASS C_ ;L X142 . .
above information is correct. I agree to comply with all County
ordinances and Statelaws relating to building construction, - -and hereby authorize representatives of this County to enter -
up the above-mentioned property for inspe tion purposes:
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent �`— / O cat
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