HomeMy Public PortalAbout6039 HART AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION 76A364C o 0 0 0
n p I� I� �p �/�
` I hereby affirm that I have a` certificate of consent to self CE -818(2-80) %A P I� l�IC A TI O � FOR I�E R UVI} T
Insure ora certificate of Workers'Compensation.Insurance,or ��� I�(^y_�( �fT1�A�l��_�I� CONDITIONING�
a certified copy thereof(Sec. 3800,Lab.C.)
Policy NS$Y_ .Company� S\_4jN
,. ❑ Certified'copy is hereby furnished.
COUNTY OF. LOS.ANGEL`ES BUILDING AND SAFETY
Certified copy is filed with the county building inspection F BUILDING
department. " OR APPLICANT TO FILL IN
Date`, Applicant_ _ QUI � ADDRESS•
_V..Jti'�_ � __ (PRINT OR TYPE ONLY)
�' LOCALITY , ?
- CEkTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE"
•COMPENSATION INSURANCE NEAREST,
CROSS ST. • },
' (This section need not be completed if the work involved ABSORPTION UNIT, BTU a.'.
.by the permit•is Jor- one hundred dollars,($100) or less.) DISTRICT NO, PROC S D BY O
I, certify that.in the performance of the work for which this -, AIR HANDLING UNIT,CFM
permit is issued, I shall not:employ any person in any manner " 0 C
so as to become subject to the'Workers' Compensation Laws.- BOILER, BTU
WSPF TOR'SSIGNATURE, V.
Date Applicant COMPRESSOR BTU
APPROVALS. DATE
ROUGH C ".
NOTICE TO APPLICANT: If, after making this Certificate:of `—
VENTILATION SYSTEM FINAL Z
Exemption, you "should become subject to the Workers'. _
Compensation provisions of the Labor Code', you-must forth-. '"
with comply with such provisions or this'permit shall be. EVAPORATIVE COOLER ALI- A
deemed revoked. FURNACE:- FAU GRAVITY
-.LI'CENSED CONTRACTORS DECLARATION FLOOR: BTU
I hereby affirm that I am licensed'urder provisions of Chapter .•, HEATER: F' DED�C UNIT rK'
9 (commencing with Section 700 0).of Division 3 of the Busi- "� ALL aV
ness and•.Professions Code,,and my license is in full force and
effect. (�
License Number��_Qz�. Lie.CIass_B=\ .
Contracto _ � . ate '
I am exempt'from the-licensing requirements as I am ,
licensed architect or- registered professional.engineer' ' Plan.check fee 25°/q•of above:
acting' in my professional 'capacity (Section' 7051, Bus- `' ' '
iness and Professions Code). . PERMIT ISSUING FEE $
,
'
..'Lie.or.Reg"No, Date. TAL FEE
TO
HOME OWNER'-BUILDER DECLARATION '
'3' PLAN CHECK APPLICANT '
I. hereby affirm that I am exempt from--the- Contractor's NAME
License Law-for the following reason (Section 7031.5 Busi
ness'and Professions Code): ADDRESS � Ne8g
.
❑ I, a's owner of the property, will,do the work and the " ,� r– (-
q., CITY `' TEL'. NO .3:3 �` lelf
structure. is'not intended or offered for sate- .(Section' _
7044, Business and Professions Code).
OWNER
ME
I, as.owner of the property, am exclusively contracting sc
❑ _
T Tt i �1
CSwith licensed contractors.to construct the project `MAIL llr k:,
(Section 7044,Business and Professions''C ADDRESS �� "_ `_. `n"s
- _ '- - ,.CHECK K 2.a 5l t�
CONSTRUCTION LENDING AGENCY CITY- ��C\ _ TEL.NOo�_altp�
I hereby affirm that there is a construction lending agency, #+��3 �.L ,z C"GE
, � irfffl!`!�
CONTRACTOR
T
for, the performance of the work for which-this permit is
issued (Sec;3097,Civ.C.). ,�.�y. q 11/
i °i„1
Lender's Name ADDRESS ; al W� 0000-000 1_ _:ti/1Ct/89
–Lender's Address CITY TEL.NO. °s '
� \. 4 6831 1 A ! ° 11.4
I certify that I have read this application and state that the STATE e r LIC.
above information is correct.I agree to comply with all County LICENSE NO. 'CLASS- 90
ordinances and State laws regulating Heating, Ventilating and '
Air Conditip in and hereorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
Coun ro enter upon thF' ov anentioned property for
n ectio ur ose� j
�ignarure of Pe,
mi ce Date _