HomeMy Public PortalAbout5825 ENCINITA AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT
1 hereby affirm that I have-a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance, '
or a certified copy thereof (Sec. 3800, Lab. C.) 76A364C HEATING - VENTILATING - AIR CONDITIONING
• - '20.0046 DPW 9/88 -
Policy No. 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 D /r
tiondepartment. ADDRESS �p,„� FC&V�71'4 V1i
(PRINT OR TYPE ONLY)
Date d Applican -
Z. NO. .TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
CERTIFICATE-OF EXEMPTION FROM WORKERS' NEAREST
• COMPENSATION INSURANCE CROSS ST.
• (Thio-section need not be comp listed ABSORPTION UNIT, BTU
ted if the work involved by [DISTRICT NO. PRCCILL—
so
as to become subject to the Workers'Compensation Laws. BOILER, BTU
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 - L
permit is issued, I shall not employ any person in any manner
APPRovnts once PE oR's SIGNATURE
Date- Applicants- 1 COMPRESSOR, BTU UO (/ 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 V LIDATIO
with comply,with such provisions or this permit shall be deem- '
ed revoked. FURNACE FAU_GRAVITY )�
LICENSED CONTRACTORS DECLARATION FLOOR . BTU I
I hereby affirm that I am licensed under provisions of Chapter 9HEATER: 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.
License Numb 2 1 ic. Class if 0
�. �A/c� . g
- Contract �x ADdte � 7 0 � oC
O
❑ • I am exempt under Sec. ' "- - U
Plan check fee
B.BP.C. for this reason. y
Date: PERMIT ISSUING FEE $ 13 00 Z
TOTAL FEE
Signature
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 - - D p -
Professions Code):
❑ ,1, as owner of the property, 'or my employees with ADDRESS ACCT i
wages as their sole compensation, will do the work and
07 59.00.:r.7
_ 37
the structure is not intended or offered for sale(Section- -CITY TEL. NO.
7044, Business and Professions Code). r
OWNER �},f/p oiti�7. COR 1 ITEM
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (sec- MAIL TOTAL. 5-5 .x 00
tion 7044, Business and Professions Code). ADDRESS / O O Q
CONSTRUCTION LENDING AGENCY CITY p,( rEL. NO. pp L•HEL.Y 5.00
I hereby affirm that there is o construction lending agency for 'S • �'-" ` �ao ��/� - fr
the performance of the work for which this permit is issued CONTRACTOR !i �/ D CHANGE .O[I
(Sec. 3097, Civ. C.).
// j/ 'r L _ -
Lender's Name ADDRESS . . •S .IJ(JOLJ-OOIJi 1I yIQO
Lenders Address CITYM No. x144 1 AM 9:2L
I certifythat I hove read this application and state that the STATE T uC. - •- - - - -
PP LICENSE NO. ,S v 3 CLA55 �.a
above information is correct. I agree
to
comply with all County _ r
ordinances and State laws relating to building construction, '
andy authorize representatives of this County to enter ,
upo t e above-mentioned pro for inspects purposes: SEE REVERSE FOR EXPLANATORY LANGUAGE
� a
Signature of Applicant or Aqent , Dat @s