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HomeMy Public PortalAbout5938 IVAR AVE_Mechanical__ WORMS' COMPENSATION have cera DECLARATION APPLICATION FOR PERMIT I hereby affirm that I have a certificate of consent to self insure, or a certific4te of Workers' Compensation Insurance, 76A364C HEATING. - VENTILATING - AIR CONDITIONING or a certified t'opy thereof (Sec.'3800; Lab. C.) 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 . tion department. p.L ��� ✓/� ,� • (PRINT OR TYPE ONLY) ADDRESS Date Applicant LOCALITY _ NO. TYPE OF APPLIANCE OR EQUIPMENT FEE G CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. (This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY the permit is For one hundred dollar 100) or less.) AIR HANDLING UNIT, CFM I certify that in the performance the ork for which this i e permit'is issued, I shall not em oy any p rson in a manner so as to become subject to th Worker O en an Laws. BOILER, BTU APPROVALS DATE INSPECTOR'S SIGNATURE Date.?a`.1/-40 Appli nt COMPRESSOR, BTU ROUGH I {� rem NOTICE TO APPLICANT: If, a er making this Certificate of VENTILATION SYSTEM FINAL 1 Exemption, you should become 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 BT 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. License Number 34 7fi7 Lic. Class C Z® a O poli. U Contract 1te��/���61 �l ad ❑ 1 am exempt under Sec. I O Plan check fee -- ,U B.&P.C. for this reason. Z PERMIT ISSUING FEE $, Date: _ TOTAL FEE Signature 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 wages as their sole compensation,will do the work and £ CITY TEL. NO. the structure is not intended or offered for sale(Section 7044, Business and Professions Code). F-1t, I, as owner of the property, am exclusively contracting OWNER with licensed contractors to construct the project (Sec- MAIL i 'iMC. tion 7044, Business and Professions Code). ADDRESS `J - CONSTRUCTION LENDING AGENCY CITY TEL. NO. 7��j � I1_tI=(� 37- 00 I hereby affirm that there is a construction lending agency for ///G . �E3 /'� f�i the performance of the work for which this permit is issued CONTRACTOR TL 1r +•��t•(+. "7 1'J-I (Sec. 3097, Civ. C.). o� / ��33 ADDRESS / 2[A t`•°�AN-GiE ,111,1 Lender's Name CITY �� TEL. NO. �'Z .� Lender's Address LI s3(3 t '' I certifythat I have read this application and state that the STATE LIC. ,7 `=` '- ' t .),E a:' tt_I PP LICENSE NO. �Y 7CLASS above' rm ion is correct. I agree to comply with all County ? `- J Art or, antes a d State la relating to building construction, J and here:) uth ize r resentatives of this County to enter upon th a ove en ' n property for inspection purposes. l SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applican or Agent Date ©s