HomeMy Public PortalAbout10919 FREER ST_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR P E RM I T
I hereby affirm certificate
fica I have r certificate ns consent To self � /�/O
'Insure, or a certlflr�te of Workers' Compensation Insurance, '/ EATING - 'VENTILATING - AIR CONDITIONING
or tf certify co thereof (Sec. 3800, b. C.) 76A36.4c
CE 18 0/81)
Policy No npany
Certified copy Is hereby furnish COUNTY OF LOS ANGELES BUILDING AND SAFETY
WRTIFITE
Prywith the county building Inspec- FOR APPLICANT TO FILL IN BUILDING
(PRINT OR TYPE ONLY) ADDRESS
Datea n t LOCALITY
NO. TYPE OF APPLIANCE OR EOUIPMEM r FEE �
PTIOVINSCE
ORKERS' NEAREST
COMPENSATION CROSS ST. zip
(This section need not be completed if tfie work Involved by ABSORPTION UN T, BTU oaru$cr
the permit Is for one hundred dollars (:100)or less.) / O�
AIR HANDLING UNIT, CFM
I certify that In the performance of.the work for which this
permit Is 1"sued, I shall not employ anypehon In any manner gptLER BTU
so as to become subject to the Worker Compensation Laws. r,PPttovNs DATE oa s SIGNATURE
Data Ilcanf COMPRESSOR, BTU ROUGH
If
NOTICE O ICANT: If, aftr nq this Corti Cate of VENTILATFON SYSTEM FINAL
Exemption, you should become led to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVG COOLER VAL(DA N
with comply with such provisions or this permlt shall be
deemed revoked. FURNACE: FAU
LICENSED CONTRACTORS DECLARATION. BOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SU&PBJDED Of UN17
'(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code,and my license Is In full force and eeff&d. -
License Num ic. Class 's
Contractp •e O
❑ I am exempt under Sec.—. Plan check fee a
N
8.8.P.O for this reason' �
PERMIT ISSUING FEE $ —
Date:
TOTAL FEE WOU
Slgrature
OWNER-13UILDER DECLARATION PLAN-CHEO(APPUCANT 7 Q17 A
I hereby affirm that I am exempt from the Contractor's License
#io oia o)0 8
Law fdr the following reason (Section 7031.5, Business and tVAhhE
Professions Code):
❑ 1, as owner of the property, or my employees with
wage"as their sole compensation,will do the work and
the structure is not Intended or offered for sale(Sectlon 011117
�'
7044, Business and Professions Code). OWNER to Io 4 a,0 0
❑ 1, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDR
CONSTRUCTION LENDING AGENCY CTY NO. _
I hereby affirm that there Is a construction lending agency for
the performance of the work for which this permit Is Issued C 4/7
(Sec. 3097, Civ.C.). 5
07, Obi8.7
ADDRESS
Lender's Name
CITY TEL NO. oo
Lender's Address
SPATE
I certify.that I have read this application and state that the UCEIJSE NO. CLASS
above Information Is correct. I agree to compty with all County
ordinances and State laws relating to bulldfn9 construction,
and hereby authorize-representatives of this County to enter
u th bov m to roperty for Irupectlon purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Sig of Applicant or Agent