HomeMy Public PortalAbout9443 LAS TUNAS DR_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATI®N fOR PERMIT
I hereby affirm that I have a.certificate of consent to self •
insure, or a certificate-of Workers' Compensation Insurance, HEATINGVENTILATING - AIR CONDITIONING
or a certified copy thereof.(Sec. 38/00' Lab. C.') .76A364C'
CE
-818(REV. 10/81)
PolicyNo ^s�C 12H� om an -1t ��it cY•)_�� S� ..
Certified copy.is-hereby:fur ni•shed:� d.F"" �J/ COUNTY OF LOS ANGELES - BUILDING'AND SAFETY
Certified copy is filed with the count building inspec-. FOR APPLICANT TO FILL IN BUIiDING,
ADDRESS.' [ 3 F V'/LaX_.
tion.depment. (PRINT OR TYPE_ONLY)
Date '/j ApplicarrL' lX�� S c �7 44,2,,Yl t k77lq _ LOCALITY'
•NO. TYPE OF APPLIANCE�OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST..
COMPENSATION INSURANCE CROSS ST.
ABSORPTION UNIT, BTU DISTRICT No: PROCESSED ev
(This section need not be•completed if the:work involved by
the permit,is for one hundred dollars ($100)or less.) 75
AIR HANDLING UNIT, CFM
I certify that in the performance-of the work for which this
permit is issued,,l shall not employ any person.in any manner' , BTU
so'as,to'become.subject to the Workers'• BOILER'
Compensation Laws. 'APPROVALS DATE I PECTOR'S SIGNAT RE
Date Applicant COMPRESSOR,BTU ROUGH _
NOTICE:TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should becorrie' subject to the Workers'
Compensationprovisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATI N
with comply with such provisions .or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY
LICENSED.CONTRACTORS DECLARATION FLOOR BTU `
I hereby affirm that I am licensed under provisions of Chapter9 HEATER: SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business WALL 3
and Professions Lode,and my license is in full force and effect.'
License Number,-//2�- Lic. Class. 3-6 /) r U
�j n j /•� ¢ /L ��s���� D
ContractoE/X' S2J Date U
I am exempt under Sec. d+
.Plan check fee �
B.BP.C. for this reason
PERMIT ISSUING FEE $" z
Date:
Signature TOTAL.'FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT -
I hereby affirm that l am exempt from the'Contractor's License
Law for the following reason (Section 7031.5, Business and NAME ^"may- �aJC� . , -
Professions Code):.
❑ I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and L c - r 2 �;-_}ri
CITY TEL. NO. �/
the structure Is not'intended or offered for sale(Sectionk%i�C, ��� 1+��d�_ _I'
7044, Business and Professions Code). OWNER - i
G r!C1DL USS, iC�! l 1 c T ��`
❑ I, as owner of the"property, am exclysively-contracting `. _ )
with licensed 'contractors to construct the project (Sec= MAIL
tion 7044, Business and Professions Code)., ADDRESS�/ /�2 yz: 7�/� LP. C 100
CONSTRUCTION LENDING AGENCY �. t'`
CITY. TEL.'NO. ,� n ��, a}=, rl
I hereby affirm that there is a construction lending agency for �i� � �r�S `' L' L
the performance of the work for.which this permit is issued CONTRACTOR'
.(Sec. 3097; Civ. C.). r Xr'.]f' TQC �:0�7� t� �r�4.�
ADDRESS
Lender's.Name i3E20.1
1
CITY( ti � TEL_NO. -� ^
p i}
Lender's Address L� �7 /� �L
STATE "., / ,2 LIC.
I certify that I have read.this application and state that the LICENSE NO. �j CLASSY --
above information is correct. I agree.to comply with.all County
ordinances and State laws relating to building construction,-
and he eby authorize representatives of this.County to enter
upon .'e above-me,tioned property for inspection.purposes.. SEE.REVERSE FOR EXPLANATORY LANGUAGE
1
Signatu e o pplicant or Agen I . A Date .-