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HomeMy Public PortalAbout4815 HALLOWELL AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT +f hereby affirm that I have a certificate of consent to self insure; or a cePtificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING or a cerdified copy thereof (Sec. 3800, Lob. C.) 76A364C 20=0046 DPW 9/88 Policy-No. Compony s -- ❑ 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. r �L ADDRESS99( w ,d r /f (PRINT OR TYPE ONLY) Date Applicant LOCALITY C V. NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM RKERS' NEAREST COMPENSATION INSURANCE CROSS ST. ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY (This section need not be completed if the work involved 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 to become subject to the Workers' Corn pensation Laws. BOILER, BTU APPROVALS D TE PVECTOR'S WINATURE Date Applicant COMPRESSOR, BTU ( t7 � - v ROUGH NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL1'1131-711 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 FSRAVITY 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. I 9L License Number { 3 Lic. Class dr lool O u Contractor ` r Date `�j~9 ad ❑ O I am exempt and Sec. Plan check fee Y -- ,V„ B.&P.C. for this reason. PERMIT ISSUING FEE $ — Z Date: _ Signature TOTAL 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 Professions Code): - .y ADDRESS .I, as owner of the property, or my employees with ❑ =' wages as their sole compensation, will do the work and ({;C ,.& the structure is not intended or offered for sale(Section CITY TEL. NO. 7044, Business and Professions Code). 017 L OWNER I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- MAIL ! =` tion 7044, Business and Professions Code). ADDRESS IC Iy-8L 57 - 00 7 m �.�v 0 CONSTRUCTION LENDING AGENCY CITY TEL. NO. t 1 hereby affirm that there is a construction lending agency for , CHECK 57 .?%i i the performance of the work for which this permit is issued CONTRACTOR C • S (Sec. 3097, Civ. C.). � •���)`'� >r. .(.l13 ADDRESS Lender's Name _ .CITY -' TEL NO. J)rl�;� i I"I a t- Lender's Address C I certifythat I have read this application and state that the STATE LIC. ,� �y PP LICENSE NO. CLASS C - !'it 1 till �a51 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 upo he abov -me ned property for inspection purposes. / D >� O SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applica r Agent Date ©s