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Home My Public Portal About4931 HELEO AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION n FF LL (J�J �( V CAIMH FOR PERT ,4.hereby'. f8 ,rm that I have a certificate'of consent to self /� N �,incure, or,q certificate of Workers' Compensation Insurance, 76A364C �ff�4�� 40d�� ®�D840®�� or a certified copy thereof (Sec. 3800, Lob. C.) bl�j 338t( 20-0046 DPW 9/88.• . Policy No.221—Ag 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. _ .Tion department.' ADDRESS �. • / ,.. (PRINT-OR.TYPE ONLY) ! Date Z -_2372'59 Applicant LOCALITY L NO.' TYPE OF APPLIANCE OR EQUIPMENT - FEE, T CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. ABSORPTION UNIT, BTU (This section.need not be completed if'the work involved by DISTRICT NO: PROCESSED BY the permit is for one hundred dollars ($100) of less.) . I'certify,that in the performance of the work for which this AIR HANDLING UNIT, CFM per`mit'19 issued,:l'shall not employ any person in any mannerV �41�J so as to become subject.to'the Workers' Compensation Laws. BOILER, BTU APPROVALS DATE INSP OR'S SIGNATURE` Date Applicant COMPRESSOR, BTU (� ROUGH - NOTICE TO APPLICANT:" If, after rnakin•'g this Certificate of VENTILATION SYSTEM FINAL Exemption,. youshouldbecome, 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 GRAVITY 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 force and effect. pT License Nu ber,�S�_ _ �n Lie. Class �j D a AA 3Asy9n A .O Contractor Date [,-2 O ❑ �3 ' I am exempt under SecaUJ BP• V B. 0 forthls,reason ' . $ d Plan check fee Date: PERMIT ISSUING FEE TOTAL,FEE c� Signature OWNER-BUILDER DECLARATION' PLAN CHECK APPLICANT - I hereby affirm that I am exempt from the Contractor's License. D """' Law for'the following reason (Section 7031.5,.Businessland. NAME Professions Code): -I, aS-owner of"The property; or my employees, with ADDRESS v ' wages as their sole compensation, will do the work and . ACI cv the structure isnot intended or offered for sale(Section CITY,. TEL.'NO. 704 Business and Professions Code). ,7.7V7 ❑ m OWNER 1, as owner of the property, aexclusively contracting• with licensed contractors to'construct the project (Sec- MAIL ..... - ADDRESS. 6 a . tion 7044, Business and Professions Code). - -' '- "' , 9. ITfi�. _ CONSTRUCTION LENDING AGENCY . CITY TEL.` TEL. NO. • � TOTAL I hereby affirm that there is a construction lending agency for 4\ECK 42.(Xl the performance of the work for which this•permit is issued CONTRACTOR �uA�� (Sec. 3097, Civ. C.). O'lCHANE ADDRESS Z `FiOGt7 f Lender's Name CITY12 • NO.Q ��y�y {�q Lender's Address � TEL.. `� ` LtuW`WVb. 6/23/89 • STATE '. ;/�+� ^7 L L . . AR! I certify that I have read this application•and state ihat'ihe LICENSE NO. CLASS C.�— c_� YhT� 1 Pili 9;57 above information is correct. I agree to comply with all County ordinances and State laws relating to building construction, an hereby authorize representatives of this County to enter up the bov-m tioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applican or Agent Date ©s