HomeMy Public PortalAbout8710 HERMOSA DR_Mechanical__ _ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance, 76A364C HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec. 3800, Lab. C.)
I ^ 20-0046 DPW 9/88
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 /n
tion department. ADDRESS
,t (PRINT OR TYPE ONLY)
Date v Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERT KATE OF EXEMP ON FROM WO KERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
(This section need not he completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROES o BY
the permit is for one hundred dollars or less.)
work
I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM C♦Jl (/iY
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. BOILER, BTU APPROVALS DATE INSPECTOR'S SIGNATURE
Dale Applicant COMPRESSOR, BTU 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 VA ID TIO
with comply with such provisions or this permit shall be deem-
ed revoked. FURNACE: FAU_GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter-9 HEATER: SUSPEND UNI /000
(commencing with Section 7000)of Division 3 of the Business WALL
and Professions Code,and my license is in full force and effect.
T
IL
License Number Lic. Class - , O
v
Contractor Date
❑ I am exempt under Sec. 0
Plan check fee v
B.&P.C. for this reason d
PERMIT ISSUING FEES b us
Dote: Z
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): _
❑ I, as owner of the property, or my employees with ADDRESS- y
wages as their sole compensation,will do the work and ACCT.r
NO
TEL. .
the structure is not intended or offered for sale(Section CITY.- 3307 ')[Is 11
7044, Business and Professions Code). OWNER
❑ I, as owner of the property, am exclusively contracting 1 ITEMS
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS TOTAL 20 n 50
CONSTRUCTION LENDING AGENCY CITY TEL. NO. CHECK 20.50
hereby affirm that there is a construction lending agency for 4 ,
the performance of the work for which this permit is issued CONTRACTOR CHANGE .00
(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name n
PP LIC
CITY TEL. NO. r 0000-0001 19/2`/89
Lender's Address '
I certifythat I have read this a lication and state that the STATE
NO. CLASS UC. :�- �4G� rt N 1 AM11:4Er
t ,
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 the above-mentioned property for inspection purposes.
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t re of Appy t or Agent Date
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