HomeMy Public PortalAbout5835 ENCINITA AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT
' I hereby affirm that 1 have a cert ifitate of consent to self
insure,.or a Lertificote of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec. 3800, Lob. C.) - 76A364C
- 20-0046 DPW 9/88 '
.Policy No. - Company ,
.❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Ceitified copy is filed with the county buildinginspec- ' FOR APPLICANT TO FILL IN BUILDING �—y T n
tion department, (PRINT OR TYPE ONLY) ADDRESS 1!/ __ . �Gl A1y7ip OL
- ,Dated/TApplicant LOCALITY Zfi GTc
O. TYPE OF APPLIANCE OR EQUIPMENT FEE
'CERTIFICATE OF EXEMPTION FROM WORKERS' - NEAREST
t - COMPENSATION INSURANCE CROSS ST.
• (This section need not be completed If the work Involved by ABSORPTION UNIT, BTU DISTRICT Na., / PR! By
the permit is for one hundred dollars (5100) or less.)
I certify that in the performance of the work for which this
permit.is issued, I shall not
nAIR HANDLING UNIT, CFM
.employ any person in any manner _
so as to become subject to the Workers' Compensation Laws. BOILER, BTU /� APPROVALS DATE INSPECTOR'S SIGNATURE
• Date Applicant - •� COMPRESSOR, BTU D a 00 ROUGH
'NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL v t
• Exemption, you ,should become subject to the Workers'
Compensation.provisions of the Labor Code, you must forth- EVAPORATIVE COOLER ALIDATI N /
-..with comply with such provisions or this permit shall be deem-
edr revoked. FURNACE: FAU GRAVITY
•'.-
A 00
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I 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.
Y
52J 2 / d
License Number--- Lic 6'?Class " 1AU, D O
Contracto--- >; � to /� / O-
❑ I am exempt under Sec. V
Plan check fee
W
BAP.C. for this reason PERMIT ISSUING FEE $ a
Date: rn
Signature
. TOTAL FEE
,.
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT - -
I hereby affirm that I am exempt from the Contractor's License D
Low for the following reason (Section 7031.5, Business and NAME
Professions Code):
ADDRESS
• ❑ 'I, as owner'of the property, of my-employees with HI L•T.i '
wages as their sole compensation, will do the work and
.the structure is not intended or offered for sole (Section CITY TEL. NO. 337 j5 f111
7044, Business and Professions Code). OWNER �L— ' _
I, as owner of the property, am exclusively contracting ��� �� 1 ITEMS
EMS
❑
with licensed contractors to construct the project (Sec- MAILC
tion 7044, Business and Professions Code). ADDRESS in &1 N� 41 TOTAL 55 0 00
CONSTRUCTION LENDING AGENCY CITY�t 3 TEL. NO. CHECK
the
c 5,00
I hereby affirm that there is a construction lending agency for ,L
CHANGE the performance of the work for which this permit is issued CONTRACTOR D. CHANGE .00
(Sec. 3097, Civ. C.).
ADDRESS�/AC J1 /1>'�G7(./TL••S ,G L, -
Lender's Name � 11000,0000 `1I 9/913
S. �� M � TEL. NO. s�y3=iu
Lender's Address CITY STATE 11C. 8,140 1 AM 9:25
1 certify that I have read this application and state that the LICENSE NO. ,y Gi CLASS q�d•U
above information is correct. I agree to comply I t
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter .
upon the above-mentioned roperty for inspection purposes. --
SEE REVERSE FOR EXPLANATORY LANGUAGE
G•_�____'�1.53 '
Signature of Applicant or Agent ate
us