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HomeMy Public PortalAbout9087 LAS TUNAS 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, or a certified copy thereof (Sec 3800, Lab C ) 76A364C HEATING - !VENTILATING - AIR CONDITIONING 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 ADDRESS (PRINT OR TYPE ONLY) Date Applicant LOCALITY�� P �� 6 1 _ NO TYPE OF APPLIANCE OR EQUIPMENT FEE 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 e permit is for one hundred dollars or less AIR HANDLING UNIT, CFM C ^6C ' certify That In the performance of the work for which this I work LiGp permit is issued,'I shall not employ any person in any manner so as to become subject to the Workers' /Compensation xLa/SBOILER, BTU� � APPROVALS DATE I INSPECTORS SIGNATURE —12,— V - �C r COMPRESSOR, BTU b0 ROUGH Date Applicant 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 VAL DAT O / with-comply with such provisions or this permit shall bd deem- ` ed revoked FURNACE FAU G LICENSED CONTRACTORS DECLARATION FLOOR BTU I her affirm that I am licensed under provisions of Chapter 9SUSPENDED UNIT (commencing with Section 7000)of Division 3 of the Business HEATER WALL and Professions Code,and my I lcen is In full force and effect 1j,AO 60 GAP C -,AV ate. License Number Lic Class , O . Confractorate- l') Ot ❑ - I am exempt under Sec _ '� O Plan check fee B&P C for this'reason W CL PERMIT ISSUING FEE $ J� 00 Date _ Signature TOTAL FEE 00 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 ❑ I, as owner of the property, or my employees with ADDRESS � wages as their sole compensation, will do the work and CITY TEL NO `•CT.V the structure is not intended or offered for sale(Section 7044, Business and Professions Code) B 1207 .51}.00 ❑ I, as owner of the property, am exclusively contracting OWNER G with licensed contractors to construct the project (Sec- MAIL 'TENS tion 7044, Business and Professions Code) ADDRESS TOTAL 0 CONSTRUCTION LENDING AGENCY CITY TEL NO I hereby affirm that there Is a construction lending agency for HECK =1.130 the performance of the work for which this permit Is Issued CONTRACT (Sec 3097, Civ C ) CHANGE e011 Lender's Name ADDRESS ' CITY TEL No00 9/12!50Lender's Address STATE LIC3� I'certify that I have read this application and state that the LICENSE NO CLASS Ca `'3 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-mentpned prof day for Inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of A cant or Agent Date ©S