Loading...
HomeMy Public PortalAbout10216 LIVE OAK AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION n P C /�y DON FOR fob 2 RN T - G'U IT L� G�1 Il 11�1 FOR I!–lS Il F5 U I hereby affirm that I have'a certificate of consent to self Insure, or a certificate of Workers Compensation Insurance,' or a fie c y thereof (Sec 3800, Lab-C HEATING - VENTILATING.- AIR C0�®1410NING certl! ) 76A364C h XW o�0 J_ 20-0046 DPW 9/88 Policy No ompanyUl42!9/ Axienut) Certified'copyis hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is,filed with the county building mspec` FOR-APPLICANT TO FILL IN BUILDING tion department , - ADDRESS v (PRINT OR TYPE ONLY) Date ` Apphcan LOCALITY NO -TYPE OF APPLIANCE OR EQUIPMENT FEE 7 CERTIFICATE OF EXEMPTION F66M WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST (This section need not be Completed'if the work involve&by ABSORPTION UNIT, BTU DISTRICT NO / PROCESSED BY t11) he permit is for one hundred dollars ($100) or less.) I certify that in the performance of the work for which this' AIR HANDLING UNIT, CFM a permit is Issued, I shall not employ any person In any manner so as to,become subject to the Workers' Compensation Laws BOILER, BTU APPROVALS DATE INS CTOR'S SIGNATURE Date Applicant COMPRESSOR, BTU - rJ ROUGH NOTICE TO'APPLICANT If, after making this Certificate of• _ VENTILATION SYSTEM FINAL Exemption,, you should become subject"to the Workers' Compensahon provision's of the Labor Code, you must forth- EVAPORATIVE,COOLER VALIDATION with comply with such provisions or this permit shall be deem- ed revoked' , • FURNACE FAUJZGRAVITY ©0 ' I• LICENSED CONTRACTORS DECLARATION FLOOR ' ` -BTU_7/• 2dd I hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED—UNI.T (commencing with Section 7000)of'Division 3 of the Business WALL- and Professions Code,and my license Is In full force and effect :'G� —Qct CL } License Number Lic ClCI s D 0 Contracto ❑ 1 am eerxempt undSec 0 Plan check feeIIAJ u B&P•C for this reason G H Date PERMIT ISSUING.FEE $ Z Signature TOTAL FEE 0 S® OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that],am exemphfrom the Contractor's License D Law for the following-reason (Section,7031.5, Business 'and', NAME Professions Code) • ADDRESS I, as,owner of The property, or my employees with, /�r/+ wages asM their sole compensation,will do the work and CITY - TEL NO CCTa4 the structure Is not Intended or offered,for sale(Section � � 7044, Business and Professions Code) OWNER❑ I, as owner of the property, am exclusively contrao'rig' /"r. LA–)P—V i ITOS with licensed contractors to construct the project (Sec- MAIL tion 7044, Business and Professions Code ADDRESS ) CONSTRUCTION LENDING AGENCYCITY TEL•NO TOTAL '_ �� �� I hereby affirm that there is a construction lending'agency foi CHECK 30,511 the performance of the work for which this permit is issued CONTRACTORD �. e (Sec 3097, Civ C ) w , ADDRESS /t) S. Lender's Name /► {y i Lender's Address CITY AG �D " TEL NO�S RR1 7/ 5/K I cert' that I have read this application and state that the STATE > LIC (F�?1 1 f '111���J�i . certify PP LICENSE NO (tom� CLASS above information is correct I agree to comply with all County ordinances and State jaws relating To building construction, ' and hereby authorize representatives of this County to enter upon the above-mentioned p perty fo nspection pun oses ' SEE REVERSE FOR EXPLANATORY LANGUAGE �' 1 Signatur f Applicant or Agent Date ©s