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HomeMy Public PortalAbout5944 HART AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION n PP �CAIWN FOR PERNT •'I•hereby.affirm that I have,a,certificate of'consent to self !/=�11T LL, l� ��J FOR lr LS INII VIl =n$ure, br.a certificate of,Workers'Compensation Insutane; y 76A364C HEATING VENTILATING AIR CONDITIONING -or-.q certified copy thereof (Sec. 38(�I), Lob: C.) 2p_ppa6 DPW 9ie8' Polity No. Company - Certified copy is hereby furnished. ' . COUNTY OF LOS ANGELES . BUILDING ARID SAFETY ❑ Certified copy is filed witF the county building inspec- FOR APPLICANT TO FILL IN BUILDING tion department. ADDRESS (PRINT OR TYPE'ONLY) Date Applicant LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE- CROSS ST. �J BTU (This section need not be completed If the WOfI(•IrIVOIV@d by ABSORPTION UNIT, DISTRICT NO: PROCESSED BY the permit is for one hundred dollars ($100) or less.) �y I certify that in the performance*of the work for which this AIR HANDLING UNIT, CFM permif is issued, I shat I not employ any person in any manner < � BTU so as to become subject to the Workers'Compensation LOWS. BOILER, APPROVALS DATE INSPECTOR'S SIGNATURE Date. �eA Applicant ' COMPRESSOR;-BTU 1 �FV ROUGH NOTICE-T6 T:_ If, after aking this ertificate—of VENTILATION SYSTEM FINAL _2 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 G AVITY v LICENSED CONTRACTORS DECLARATION FLOOR ' BTUW=tQr;frJw I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT— (commencing NIT—(commencing with Section 7000)of'Division 3 bf the Business WALL, and Professions Code,and my license is in full force and effect. CL License Number , LLiic. C/lasA O ContractorT'� i IIX 'I am exempt under Sec. 0 Plan check fee v W B.&P.G. for this reason. r N Ddte: PERMIT ISSUING FEE $ Z TOTAL FEE Signature OWN -B OftDM 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 D Professions Code): ADDRESS-- &I C ❑ I, as owner of the property, or my employees with ;,f..y. wages as Their sole compensation,will do the work and 3t• ?�e ' the structure isnot intended or offered for sale(Section CITY -L-7AZ c —:TEL. NO._.. 7044,Business and Professions Code). OWN � ^� ❑ I, as;owner of the property, am ezclusively'contracting ER,; b�21-�e�. L J T iT`'i'_ with licensed contractors to construct the project (Sec- MAIL //��p �, / / tion 7044, Business and Professions Code ). ADDRESS .. 0� ./v v . TOTAIL —_ 00 CONSTRUCTION LENDING AGENCY lm CITY TEL. NO. I hereby affirm that there is a construction lending agency for CHECK _ e !J the performance of the work for which this permit is issued CONTRACTORr` (Sec. 3097, Civ. C.). D CHANGE ADDRESS, awz 1A - - Lender's NameCITY "D 26 Lender's Address 10 30 3( "f J 7 7't I certify that I have read this application and state that the LICENSE NO.STATE CLASS �i -.001 r 1" AN ("'hI above information is correct. I agree to comply with all County /' L v ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter upon the above-mentio ed property for inspection purposes. ' SEE REVERSE FOR EXPLANATORY LANGUAGE Signature App i nor Agen Date ©S