HomeMy Public PortalAbout5827 ENCINITA AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION�I FOR PERMIT
- I hereby affirm that I have a certifimte,of consent to self -
insure, or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
• or a certified copy thereof (Sec. 3800, Lob. C.) ]6A364C >
20-0046 DPW 9/88
Policy No. Company - - -
&I-tified copy is.hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY , -
„r ®� Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING �/
tion department. - ADDRESS S8� DV61AJI- ,Q ;,6WO_
(PRINTORTYPE ONLY) - - -
'1' Date- Applicant ,. LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST U q
COMPENSATION INSURANCE CROSS ST. N
ABSORPTION UNIT, BTU
• ,.
(This section need not be completed If the work involved by alsrRlcr No. PRoce
the permit is for one hundred dollars ($100) or less.) . D�/
I certify that. in the performance of the work for which this AIRHANDLINGUNIT, CFM_ I✓'l I/A
permit is.issued, I shall not'employ any.,person in any manner _
- so as to become subject to theBOILER, BTU,Workers' Compensation laws.' APPRovALs Dgre INSPECTo 'S SICNAnRE
Date Applicant' • COMPRESSOR, BTU /,odsIn 00 ROUGH
+4 I
NOTICETO APPLICANT: If, after making this'Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers' tl '
Compensation'provisions of the Labor Code, you must forth- EVAPORATIVE COOLER v LIDATION
with comply with such provisions or this permit.shall bedeem-
ad revoked.- FURNACE. FAU_GRAVITY
LICENSED CONTRACTORS DECLARATION FLOORBTUJa
L
hereby affirm that I am licensed under provisions;of Chapter 9 HEATER: SUSPENDED UNIT
+ (commencing with Section 7000pof Division'3 of the Business WALL
and Professions Code,and my license is in full force and effect.
License Number �� Lie Class �� D a
�JV
Contractor Date !`1021_2 O — - '
❑ O am'ezeI mpt'under Sec.
Plan check fee v
B.BP.C. for this reason: d
PERMIT ISSUING FEE $ un
Ddte: z
Signature - TOTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
.. Thereby affirm that I am.exempt from the Contractor's License
Low for the following reason (Section 7031'.5, Business and NAME - D,
Professions Code):
- 'r- ADDRESS-
❑ I,
-as owner of the property, or my- employees with A
wages as their sole compensation,will do the,work and Al(•T.e
.:.-..... TEL. NO.
- the structure is not intended orbffered for sale (Section- CITY `30 . er•I3(�
1
7044, Business and Professions Code). - OWNER D pOti/
El 1, as owner cif the property, am exclusively,contracting - 1 LTEhi5
with licensed contractors to construct the project (Sec- MAIL nnA r• 0
tion 7044, Business and Professions Code). ADDRESS.- K�T _0 p TOTALTOTAL 55 a iJ
.CONSTRUCTION LENDING AGENCY. - CITY _44A,( kcS.Q�f
1 hereby affirm that there is a construction lending agency for ��'£« TEL NO."B..->>�8 CHECt'� - •!
the performance of the work for which this permit is issued CONTRACTOR -7- G .G+ 7�� D CHANGE •ITU
(Sec. 3097, Civ. C'.).
ADDRESS
Lender's Name 7• ���/t� 3I" - •• - -
CITY J: ��tijo J TEL. NO: �' .�� G000-0001 iJ G/4U
Lender's Address '' 1 AN 9e2&
_
I certify that I have read this application and state that the STATE STATELICIENNO. .S,3 �-3
LIC.CLASS x14:1 d
above informof ion 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 t e above-mentioned pro erty forinspe tion purposes. - -
SEE REVERSE FOR EXPLANATORY LANGUAGE
D
Signature of Applicant or Agen ate