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HomeMy Public PortalAbout6324 ENCINITA AVE_Mechanical__ WORKER'S I2MO4 SCOMPENSATIONDECLARATION -DPW9/s4 APPLICATION FOR PERMIT UAAE GREEN I hereby affirm that have,,a certificate of consent to self insure, 76A36HC or a certificate of Worlker's.Compensation In urence, or a c hied HEATING -VENTILATING• AIR CONDITIONING` copy thereof4Sec.380 Lab. O4 L S / Policy o. company_ COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. Certified copy is hereby furnished. Certified copy is filed with the I nt buildingaction FOR APPLICANT TO FILL IN BUILDING / ! ❑ de amen y (PRINT OR TYPE ONLY) ADDRESS G)�) Date�A7PIi n LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE G CERTIFICATE OF EX P ION FROM WORKERS' NEAREST CROSS ST. COMPENSATION INSURANCE ABSORPTION UNIT,BTU (This section need not be completed if the work Involved by the MAPESSOR BOOK PAGE PARCEL' permit is for one,hundred tloliars($100).or less.) AIR HANDLING UNIT,CFM nOIS,=NO. P OCEESED BY I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to BOILER,BTU become subject to the Workers' Compensation Laws. COMPRESSOR,BTU 60 67O RPPROVRLs DATE INSPECTORS SIONATIINE Dale Applicant VENTILATION SYSTEM NOTICE TO APPLICANT: If, aftermaking this Certificate of ROUGH Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code, you must forthwith comply with such FINAL s provisions or this permitshall be deemed revoked r FURNACE: FAU VALIDATION LICENSED CONTRACTORS DECLARATION I FLOOR BTU Il I hereby affirm that I am licensed under.provisions of Chapter 9 SUSPENDED—UNIT— (commencing USPENDED UNIT_(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL Professions Code,and my license is in full force and effect. License Number.-, ��Lic. less ✓ `-"" � �_� C 0- Contractor _ DateG �7 V D 0 ❑ I am exempt under Sec. Plan check fee - Q BAP.C.for this reason - PERMIT ISSUING-FEE$ (� O Date: TOTAL FEE Ir- O - U W `Signature d PLAN CHECK APPLICANT (1) OWNER-BUILDER DECLARATION - Z I hereby affirm that I am exempt from the Contractor's License Law NAMEC�ytxr h1 for the following reason (Section 7031.5, Business and Professions v/„ © 1 ITEMS Code): ADDRESS .(f{,M`.TI y 143 s 50 ❑ I, as owner of the property, or my employees with wages 4S EA �fjTit`9l tpTiL ii/4� 4��Jpp as their sole compensation, will do the work and the CITU ; TEL.NO. - Cr1@QK ti9%7N structure is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER CHANGE .00 ❑ I, as owner of the property, am exclusively contracting MAIL with licensed contractors to construct the project (Sec. ADDRESS - tion 7044, Business and Professions Code). CITY TEL.NO. WOO-0001 6/27/96 CONSTRUCTION LENDING AGENCY I he�by affirm that.there is a construction lending CONTRACTOR ing agency for - 7153 1 AM/8%57 h:,performance of the work for which this permit Is issued D / (Sec.3097,Civ.C.). ADDRESS FAId Lender's.Name CITY TEL.NO.6/9 ZyQ Lender's Address STATEC( LIC. I certify that I have read this application and state that the above LICENSE O. Cf 2- CLASS CSW informatio is correct. I agree to comply with all County ordinances and Stat ws rela41hisnty I cling construction,and hereby authorize rep sen fives of to enter upon he bove entioned pos ^� SEE REVERSE FOR EXPLANATORY LANGUAGE SIV AGIbrKePUKAW OR AGENT ejkTE(./f