HomeMy Public PortalAbout10534 FREER ST_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec. 3800, Lab. C.) 76A364C
20-0046 DPW 9188
Policy No. Company S
F-1 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
tion department. ADDRESS
(PRINT OR TYPE ONLY)
Date Applicant LOCALITY r
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST. ,,✓
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY
the permit is for one hundred dollars ($100) or less.)
AIR HANDLING UNIT, CFM
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 10 become subject to the Workers' Compepadfion Laws. BOILER, BTU APPROVALS DATE INSPECTOR'S SIGNATURE
COMPRESSOR, BTU d ROUGH
Date � Applicant--��r� �--""""'
NOTICE TO APPLICANT: If, afttor""tri king 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 VALIDATION
with comply with such provisions or this permit shall be deem-
ed revoked. ! FURNACE: FAU GRAVITY
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. s / 7
License Number " '" Lic. Class G
auV
Contractor Date
U.
am exempt under Sec. }
Plan check fee nl:
Q
B.&P.C. for this reason. PERMIT ISSUING FEE $ 0
Date:
Tf'
Signature —TOT AL FEE
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 f; x'
Professions Code):
❑ I, as owner of the property, or my employees with ADDRESS ;
wages as their sole compensation, will do the work and
the structure is not intended or offered for sale(Section CITY TEL. NO.
7044, Business and Professions Code). OWNER
❑ 1, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS i...
CONSTRUCTION LENDING AGENCY CITY / TEL. NO.
I hereby affirm that there is a construction lending agency for ,
the performance of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.).
ADDRESS _
Lender's Name "
CITY " /� TEL. NO.
Lender's Address
ATE LIC.
I certify that I have read this application and state that the uCENSE NO. J, C-) CLASS
above information is corre t. I agree to comply with all County
ordinances and State--f5ws relating to building construction,
and hereby autfrorize representatives of this County to enter
upon The2� ave";[ boned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
.Signature of Applicant or Agent Date1
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