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HomeMy Public PortalAbout9067 HERMOSA DR_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT I hereby affirm that I have a certificate of consent to self /'1f /Y '`� r Gll'Y, Insure, or a cerlificatetof Workers' Compensation Insurance, �6as64c HEATING - VENTILATING • AIR CONDITIONING s or ofWer��-f`}'�¢d copy thereof (Sec. 3800, Lob. C.) Policy Np! I��I Company rQ2r0 n p"OD46 DPW 9/BB T COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is hereby furnished. ® Certifie&cppy is filed with the county building inspeG FOR APPLICANT TO FILL IN BUILDING ee- tion department. _ _ ADDRESS Q [�/Z�YL D—C 4 D✓�1� - { �/q e ,I/ /�, (PRINT OR TYPE ONLY) a e•- /-4— • ' Applicant v I (T ,41. )02r(! - - - LOCALITY �p /e �2c - • NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE _ CROSS ST. BTU (This section.need not be completed if the work involved by ABSORPTION UNIT, DISTRICT No P EssEo ev +the permit.is,for one hundred collors'($100) or less.) t_.;(,certify that in the performonceof the work for which this AIR HANDLING UNIT, CFM Perm it,is Issued, t.I shall noemploy any person in any manner ' sops to become subject to the Workers'CampeasatlOaLaws. BOILER, BTU APPROVALS DATE. INSPECTOR'S SIGNATURE Date Applicant +' COMPRESSOR, BTU 2 0 ROUGH ;'NOTICE TO APPLICANT: if, after making this Certificate of. VENTILATION SYSTEM FINAL 'Exemption, you should become'subject to the Workers' r Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER V I k T with comply with such provisions or this permit shall be deem- " eci revoked: .! FURNACE: FAU__G VITY / LICENSED CONTRACTORS DECLARATION FLOOR BTU , ''I h'erebyaffirm that I am licensed under provisions of Chapter 9HEATER: 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. License Numb 9`027<3S Lia Class Xcty 039 Number a Confractor C✓9F'�e" .L-s+VNa 2 _ Dot Y r�—g/ , m 0 am exempt under Sec. • - - _ Pldn check fee � • + •B'BP.C. for this reason. - Wai Date: PERMIT ISSUING FEE $ v Z Signature TOTAL,FEE — OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT ' - -" I hereby affirm that.I am exempt from the Contractor's License poll , Law for the following reason (Section 7031.5, Business and NAME ' Professions Code): ❑ 1, as owner of the property, or my employees with ADDRESS • 4 • - wages as their sole compensation,will do the work and - �U'I'T•T _ _ the structure is not intended or offered for sale(Section CITY., ` L' - ��� -i - -� 7- C- 7044, Business and Professions Code). OWNER ,. i3y/� S7`�9dleQ " ❑ I, as owner of the property, am exclusively contracting - 1 ITEMS ' with licensed contractors to construct the project (Sec- MAIL `?o _' tion 7044, Business and Professions Code). ADDRESS- - /�L7 e/LMd .1,(0 7 TOT AL +� m �� CONSTRUCTION LENDING AGENCY.. -- ary TP /,�. (°i f TEL. No. VC-3IS-7t:HEt:�'. 37JlI"t I hereby affirm that.ihere is a construction lending agency For. ' p . . the performance of the work for which this permit is issued- CONTRACTOR eW OA �7� CONS T�r/G - CMANGE .10 - (Sec. 3097, Civ. C.). Lender's Name a T, ADDRESS 41 A1,7AI 4/V�r aTY. .�en• /e Pi'f TEL NO. �_2 1 I;fjlil! I;L�1�1 8124/ Lender's Address - I'certif that I have read this application and state that the STATE y •� LIC �• 7 - - .Fcl - '1 'FIN11��1f� Y PP LICENSE NO. D c� 76S CLASS p CAy C0.5 above information is correct. I agree to comply with all County - ordinances and State laws relating,to building construction, - - - - -- - - - "" - and hereby authorize representatives ofthisCounty to enter &he above-mens ionedd propp�y for inspe<tion'purposes. ' " --' '- " • ^ SEE REVERSE FOR EXPLANATORY LANGUAGE Signaturevof Applicant or.Agent Date - ©s