HomeMy Public PortalAbout9819 LAS TUNAS DR_Mechanical__ WORKER'S COMPENSATION DECLARATION 46DPW 9/89
76A364C APPLICATION FOR PERMIT LIME GREEN
• 76A3
I hejeby affirm that I have a certificate of consent to self insure,
dr a certji�ate of WErker's Compensation Insurance, or a certified HEATING - VENTILATING - AIR CONDITIONING
copy thereof(Sec. 38`00 Lab.C.) A,�
Policy No.144.2-43 Company SJAZ?r- fi[J,OD
COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
Certified co FOR APPLICANT TO FILL IN BUILDING
copy is filed with the county building inspection ADDRESS
department.
(PRINT C TYPE ONLY) ��
�77 LOCALITY 9
Date '��fy:— � Applicant �`' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE 'r It _.,v '--, 1751 � art
l
NEAREST
CERTIFICATE OF EXEMPTION FRO ORKERS' CROSS ST � ��✓�i(/
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
ASSESSOR
(This section need not be completed if the work involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESS BV
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER.BTU Q
become subject to the Workers' Compensation Laws.
COMPRESSOR,BTU APPROVALS�
APPROVALS DATE INSPE TOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers' Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL Z�
provisions or this permit shall be deemed revoked. FURNACE: FAU IL GRAVITY
LICENSED CONTRACTORS DECLARATION / FLOOR BTU �C V LID TION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and HEATER:
WALL
Professions Code, and my license is in full force and effect. 7
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License Number �� ( Lic.Class ��«•L�� 'Y f x , _
1 I I
i T EM
M + }
- � Date fiJ�'' Ct 1:.� C
0.
Contractor i C
F-1 I am exempt u er ec. Plan check fee TI�I H'L 11 a -�'-_' C
t Q
B.BP.C.for this reason PERMIT ISSUING FEE$ CHECK 114.t•J C
Date: �:i�fiNt�E .1313 Ic
LL
TOTAL FEE
fa
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT Ui �tl-[I�Ifii =;ij tDy L
I hereby affirm that I am exempt from the Contractor's License Law NAME / / , CiLi
for the following reason (Section 7031.5, Business and Professions Z_ v 3-] 1 ;7`1 n t '
Code): ADDRESS t/
1, as owner of the property, or my employees with wages n
as their sole compensation, will do the work and the CITY ,) EL.NO. ,�IGt=S f
structure is not intended or offered for sale (Section 7044, (J
Business and Professions Code). OWNER C
❑ I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
CITY
CONSTRUCTION LENDING AGENCY
F
Ihereby affirm that there is a construction lending agency for �r' ►
the performance of the work for which this permit Is issuCONTRACTOR ed 7 w/�
(Sec. 3097, Civ. C.). /A
ADDRESS l21^
Lender's Name CITY S / /"'�Q� 'f TEL.NO. e.IlIf_3
Lender's Address STATE ` LIC.
I certify that I have read this application and state that the above LICENSE NO, S6 CLASS
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
proper for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNAr �.11NT DATE