HomeMy Public PortalAbout6011 HART AVE_Mechanical__ v• �; WORKERS'COMPENSATION DECLARATION, n PPn C ^ TMUM FOR FIERMT
figa•'eby affirm that I have a certificate of consent to self (� �L /� IJ�J j� (JwJ(J
Insure, or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
ora ti ae o y ther o Sec. 0 ab. C.) , 76A364C ,
�1 ®,Z3� • J �j 4E-818(REV. 10/81)
Policy No. - Company
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 <J f
tion department. 1 ADDRESS 1/�f
p (PRINT OR TYPE ONLY)
Date � —1/ —O if Applicant LOCALITY /iAk
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE c'i
CERTIFICATE OF EXEMPTI FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
BTU DISTRICT NO. PROCESSED BY '
(This secfion need not be completed if the work involved by ABSORPTION UNIT, _
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 �c
permit is issued, I shall not employ any person in any manner BOILER, BTU
so as to become subject to the Workers'Compensation Laws. APPROVALS DATE I/ PE O 'S SIGNATURE
Date Applicant COMPRESSOR, BTU j �0 ROUGH
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
deemed revoked. FURNACE:. FAU, RVT00
LICENSED CONTRACTORS.DECLARATION FLOOR BTU O
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 forcle and effect. r 1N�e 13
License Number ®r+ Lic. Class C. '? 0 1, V
Contractor ' Date .+ �/ �� O
Ie
❑. I am exempt under Sec. n
Plan check fee # 9
B:BP:C. for this reason_ 10
PERMIT ISSUING FEE $ ��. O Z
Date: '
Signature
TOTAL' FEE 3 aS
OWNER-BUILDER DECLARATION PLAN CHECK'APPLICA NT.` o,e 3 9.2 5
I hereby affirm that I am exempt from the Contractor's License D
Law for the following reason. (Section 7031.5, Business and NAME _
Professions Code): t.e o 0 392
,
❑ I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do,the work and 5 9"8 8
the structure is not intended or offered for sale(Section CITY TEL. NO.
7044, Business and Professions Code).
' 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 (P
CONSTRUCTION LENDING AGENCY CITY r TEL. NO
I hereby affirm that there.is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTORf ,�1 D '
(Sec. 3097, Civ. C.).
ADDRESS•-
Lender's Name
Lender's Address C16?6"=l f1lo TEL. NO.91f//
STATE LIC. /1
I certify that I'have read this application and state that the LICENSE NO. �C ® p� CLASS �j(j`
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 bovpTentioned property for inspection purposes. -SEE REVERSE FOR EXPLANATORY LANGUAGE
rIII, _ // �
Signa re of Applicant 'r enDate - - `- -