HomeMy Public PortalAbout10870 FREER ST_Mechanical__ � WORKERS' COITION DECLARATION APPLICATION FOR PERMIT
,"•hereby
affirm that I have a certificate of consent to self
Inlure, or a certificate of Workws Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
,*or.a*Fled copy thereof (Sec. 3800, Lab. C.) 76A.164C
yU 20.0646 DPW 9/88
*011■y No,! Company
Rn C ad copy Is hereby furnished. COUNTY OF LOS ANGELES BUILD AND SAFETY
Certified copy Is filed with the county building Inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. 12
(PRINT OR TYPE ONLY) ADDRESS
Date ApplIcant LOc- L
NK). TYPE OF APPIIAINCE OR EQUIPMENT FEE
CERTIFICATE OF D(EAAPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
(This sectlon need not be completed If the yogic Involved by ABSORPTION UNIT, BTU DMTRKi N%a B
the permit is for one hLrndred dollars ($100) or less.)
1 certify that In the performance of the work for which this NR HANDLING UNIT, CFM L 1'
permit is Issued, I shall not employ any person In any manner BOILER,
L__
so as to become subrect to the Workers' Compensation Laws. BOILER BTU APPROVALS' DATE r>SPFCTOR-s srNAnm
Datllcant COMPRESSOR, BTU ROUGH
NOTICE TO APPLICANT: ff, 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 V n
with compI with such provisions or this pgrmit shall be deem-
ad
eem
ed revoked. ( FURNACE: FAUFLOORGRAvrTY O
LICENSED CONTRACTORS DECLARATION i BTU
I heroby afflFm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED UNIT—
(coyumencing with Section 7000)of Division 3 of the Buslness WALL
anx Professions Code,and my II Is In full force and effect.nn !1
7 l/ }
C CL
License Number Ic. Classy Poo. O
V
Contractor Date
❑ I am exempt under Sec. Pian check fee
Uj
B.BP.0 for this IL
reason PERMIT ISSUING FEE $ a
Date: Z
TOTAL FEE
Slgrxrturw v �
OWNER-B I DER 1ECONRATION PLAN CXEC(APPLICANT
I hereby affirm that I am exempt frgm the Contractors Llcenso ,
Law for the following reason (Section 7031.5, Business and NAME \C
Professions Code): d�
Fj 1, as owner of the property, or my employees with ADDRESS30( t
wages as their sole compensatlori,will do the work and ACGT.r
the structure Is not Inter�ded or offero for sale(Section Crit �Pl — d
7044, Business and Professions Coda). 7 '�
oavrrER 1 ITBE
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the protect (Seo- MAIL
tion 7044, Business and Professions Code). `DDRE55 '�" TOTAL 34 . 00
CONSTRUCTION LENDING AGENCY }
CITY TEL NO. O CW�; 34.0(1
affirm I hereby arm that there Is a construction lending age'rity.for. ,
the performance of the work for which this permit is-issued CONTRACTOR } ■W
(Sec. 3097, Civ. C_).
ADDRESS
Lenders Name y_�-yy L
CITY TEl. NO. DODD-f�D01 101 Of07
Lenders Address STATE
1 certify that I have rood this application and statq� that the UCENSE NO CLASS
U — �� 7 1 Ar11D�5$
above Informatlon Is correct. I agree to comply with 311 County
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
up-0 'the above-mentioned property for Inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Slgnatu Applicant or Agent Date �s