HomeMy Public PortalAbout9102 HERMOSA DR_Mechanical__ WORKERS' COMPENSATION DECLARATION A PPLICATION ,COO PERMIT
I.hereby affirm that I have a Certificate of consent to self�.' _ /'1r \.r r R G I
insure„pr a certificate of Workers' Compensation Insurance,.
or a certified copy thereof.(Sec. 3800, Lab. C.) - 76A364C HEATING ; VENTILATING • AIR CONDITIONING ,
. 20-0046 DPW 9/88
Policy No. Company COUNTY OF LOS ANGELES BUILDING AND SAFETY
-� Certified copy is hereby furnished:'• '
T ,Certified copy is filed with The county building inspec- FOR APPLICANT TO FILL IN BUILDING
ariment.
-
❑
tion de . ADDRESS O
P., (PRINT OR TYPE ONLY)
;DateApplicant LOCALITY T �- L �7•-T
No: TYPE OF APPLIANCE OR EQUIPMENT- - FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' - NEAREST '
COMPENSATION INSURANCE CROSS ST. _TFL4_1_T
ABSORPTION UNIT, BTU
(This section need not be,completed if the work involved by DISTRICT No. PROC o BY '
the permit is for one hundred'
undred dollars ($100) or less.) _ !'•`
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 .. ✓ D '
so a`'s Io become subject to the Workers' Compensation Laws. BOILER, BTU APPROVALS DATE INSPECTOR'S SIGNATURE
.Date Applicant
-r - COMPRESSOR, BTU Lie, ROUGH
NOTICE TO APPLICANT: If, aftei 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 VALIDA ION '
with comply with such provisions or this permit shall be deem- . ,.
.ed revoked. FURNACE: 'FAD=GRAVITY
LICENSED CONTRACTORS DECLARATIONFLOOR BTU '
Thereby affirm that 1 am licensed under provisions of Chapter HEATER: SUSPENDED UNIT
n — '
(commenng whh�Sectiom 7000)of Division of the Business WALL '
and Professions Code;and my license is:in full force and effect.
License•Number Lic Class , _ O
Contractor - Date—I of
❑ -I am 1.exempt under Seca . O
Plan check fee
•B.BP.C. for thls,reason d -
PERMIT ISSUING FEE $ ^
Date: Z
' TOTAL FEESignature
OWNER-BUILDER DECLARATION PLAN CHEEKAPPUCANT - -
I hereby affirm that I am exempt from the Contractor's License /
Law for the following reason (Section 7031.5, Business and NAME , f=' � ijr - , . - .....
Professions Code): - - - ....... '
'{7f ` ADDRESS L7 -
J - ._
' I; as owner.of the property, or my employees with � 0 y �. � 0'Eit� �''
'
wages as their sole compensation,will do the work and SJ AC:4T.r
the structure.is not intended or offered fonsale(Section CITY rt-c- �t�` TEL. NO !� r 0 .... . -... -
AI
7044, Business and Professions Code). -OWNER /- f - ”- - 3307,
307 37.50
,. , C.
.I„as owner of.the property, am exclusivelyconfracting /'. - r . •L V �yf� ' T��h1C
with,.icensed'contracfors to construct the,pro jeer (Sec MAIL y _ .-.,._ _ ITEMS
ADDRESS' �' %� rr ��,�y z—' � ..._..
tion 7000 Business and Professions Code). .. TOTAL LENDING AGENCY OTAL +�
OTv r� S- I .�i
HELM
' I hereby affirm that there is a construction lending agency for �f. '�-� -�I-t TEL N J 6 , CHECK,` ..37,r}[i
the performance of the work for which this permit is issued CONTRACTOR
(Sep..3097, Civ. C.). CHANGE .00
,. ADDRESS. .. .. ..
Lender's Name
Lender's Address' �rr {}
CITY ` TEL. NO. 0000-0C101 .1V7.,'.57VrL]
_ _ _ t AM o
1 certify that have read This application and state .1 the LICENAT'SE NO. CLASS bJ14 1 AM 9:19
above information is correct'I agree to comply with aII
ll County, ,
ordinances and State aws.relating to building construction, -
and hereby autktri2�e representatives of this County to enter
u e abo tioned property for ins ecfion -
-, SEE REVERSE FOR EXPLANATORY LANGUAGE
gri of A is nt or Agent