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HomeMy Public PortalAbout10535 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 9/88 Policy No, Company >A�f ti ,�yY1 Certified cdpy 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.' I ADDRESS (PRINT OR TYPE ONLY) Date `A licant• /�' LOCALITY PP NO TYPE OF.APPLIANCE OR EQUIPMENT FEE. F / c CERTIFICATE OF EXEMP N FROM WORKERS' NEAREST' COMPENSATION INSURANCE CROSS ST (This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO PR SED BY the permit is for one hundred dollars ($100) or'less.) G4 I certify that in the performance of the,work for,which this AIR HANDLING UNIT, CFM ` permit is issued, I shall not employ any person In any manner- so as to become sublect to the Workers'Compensation Laws. BOILER, BTU APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant COMPRESSOR, BTU ROUGH 4 NOTICE TO APPLICANT: If, after making 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.ls in full force and effect. awl C�� ' jk`�rt �u�f Q CL License Number L Llc. Class , Contractor Date I b O oe ❑ I am exempt under Sec. O Plan check fee V B.&P.C. for this reason ' rJ O w }e: PERMIT ISSUING FEE $ Z Signature TOTAL FEE 5 NER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor's License 1 , Law for the following reason (Section 7031.5,.Business and NAME ; Professions Code): I, as owner of the property,'or my employees with ADDRESS T - wages as their sole compensation, will do the work-and CITY TEL NO Ff�•s f `g the structure is not intended or offered for sale(Section _ 7044,•Business and Professions Code). 3301 1.1.50 OWNER ❑• 1, as owner of the property, am exclusively contracting 1 1 i EMS with licensed contractors to construct The project (Sec- MAIL tion 7044; Business and Professions Code). ADDRESS TOTAL 15 50 CONSTRUCTION LENDING AGENCY. CITY TEL NO .I hereby affirm that there is a construction lending agency for CHECK 15.5(t- the performance of the work for which this permit Is Issued CONTRACTOR (Sec. 3097, Civ. C pop CHANGE UT Lender's Name ADDRESS CITY}, Z./� TEL N0.7�1? ? n / . OOCID-0001 10/16/89. - Lender's Address I certifythat I have read this application and state that the [STATES LIC 62-61 -1 AN 9; 1 PP ENE NO. �) L CLASS above information 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 above-mentioned property for inspection purposes. ••- - I SEE.REVERSE FOR EXPLANATORY LANGUAGE ' gnature of Applicant or-Agent Date ©s