HomeMy Public PortalAbout9837 ESTRELLA AVE_Mechanical__ .•-WQRKER'S COMPENSATION DECLARATION 200046 DPW 9/B9
76A364D APPLICATION FOR PERMIT hereby affirm that t LICA GREE .have a certificate of consent to seli'insure, .. r
or a certificate of Worker's Compensation Insurance, or a certified HEATING- VENTILATING-AIR CONDITIONING
copy thereof( e 800 Lab.
Policy No.1I11���1 ompany 'V COUNTY OF LOS ANGELES DEPTOF PUBLIC WORKS BUILDING AND SAFETY DIV.
Cenified.copy is hereby furnished.
Certified copy is filed with the cc u bu iltlin Ins act FOR APPLICANT TO FILL IN 9ULOWG
Y 9 P - ADDRESS
it art ant. (PRINT OR TYPE ONLY)
Date / Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE V
CERTIFICATE OF EXEMPTION FROM WORKERS' - NEAREST
CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU '
SSOR
(This section need not be completed if the work involved,by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100).or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for.which this permit
is issued, I shall not employ any person in any.manner so as to BOILER,BTU y
become subject to the Workers' Compensation Laws.
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR's SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of _ ROUGH
Exemption, you should become subject to the Workers' Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such - FINAL _ I Al
-
provisions or this permit shall be deemed revoked.. °- t FURNACE: FAU GR VIN
LICENSED CONTRACTORS DECLARATION FLOOR BTU U VALIDATION
I hereby affirm that I am licensed'_under provisions of Chapter 9 HEATER: SUSPENDED UNIT_
(commencing with Section 7000) of Division.3 of the Business and WALL
Professions Code, andrmy license is in full force
and effecctt////�a
License Number Lic. aCl 5s0AZ'f(g[L _ - •}
./7/� D _
/
-Contracto r//� 0_4A� o
_ O
- - ,
I am exempt Pian check fee under Sec. O
BSP.C.for this reason PERMIT ISSUING FEE$ ff pe )—
U
Date: .TOTAL FEE - .+ W
ov
a
Signature OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT _ Z
I hereby affirm that I am exempt from the Contractor's License Law NAME
for the following reason (Section 7031.5, Business and Professions _
Code): ADDRESS _ -4 1:I'oi
1, as owner,of the property, or my employees with wages' 1(-r - ( 1`0
as their sale compensation, will do-the work and the CITY TEL.NO.
structure is not Intended or offered for sale (Section 7044, C1:.
Business and Professions Code). OWNER - �'• 1 I I t`
1, as owner of the property, am exclusively contracting MAIL /' TIIi�, :37 06
with licensed contractors to construct the.project (Sec- ADDRESS -
tion.7044, Business and ProfessionsCode).
CITU TEL NO.
' CONSTRUCTION LENDING AGENCY � + Ll pij� elStl
.I hereby,affirm that there is a construction lending agency for CONTRACTOR
the performance of the work for which.this permit Is issued
(Sec.3097, Civ.C.).
/ J C
Lender's Name ADDRESS ,,�j i - IJI)I�I_'—iJIJI�i 1
CITY "/ ' TEL.NO.
Lender's Address STATE J LIC: - - -
.I certify that I have read this application and state that the above LICENSE NO. CLAS
information is correct. Iagree to comply with all County ordinances
and Stat aws relating to building construction,and hereby authorize
.repr s atives of this County to enter upon the ove-me tioned
rt I p do purposes. .SEE REVERSE FOR EXPLANATORY LANGUAGE
SI RE 15FF LICANT OR AGE DAVE