HomeMy Public PortalAbout9510 LAS TUNAS DR_Mechanical__ µWORKER'S COMPENSATION DECLARATION 2D_UD46DPW 9,69 APPLICATION FOR PERMIT LIME, GREEN
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hereby affirm that I have a certificate of consent to self insure,
or a certificate of worker's Compensation Insurance, or a certified HEATING -VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab. CJ
Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
❑ Certified co is filed with the count buildin I spectio FOR APPLICANT TO FILL IN BUILDING / /�. 1U�a
PY Y 9 ADDRESS L, r
departure t. (PRINT OR TYPE ONLY)'
LOCALITY
Data Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS ST.
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($100)or less.) AIR HANDLING UNIT,CFM
_ DISTRICT NO. - PROCESSED BY
I certify that in the performance of the work for which this permit / ("//
is issued, I shall not em toy any person in any me er a to BOILER,BTU L 9i ,(
become subject tot mpensation s. f/J C/} d((//
COMPRESSOR,BTU -4r /O`-ea.
APPROVALS DATE INSPECTOR'S SIGNATURE
• Date Appli, nt VENTILATION SYSTEM ,p
NOTICE'YO A PLICANT: If, after making Is Certificate of ROUGH 3/8-91 L1 ..
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,'you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY'
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect.
C7 o b
r
License Number Lic.Class
CL
Contractor e d ' O
ElPlan check fee U
I am exempt un r Sec. dZ Q O
B.&P.C.for this reason PERMIT ISSUING FEE$ F--
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Date: TOTAL FEE ®Q d
Signature (n
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
C0
hereby affirm that I am exempt from the Contractor's License Law NAME =`
for the following reason (Section 7031.5, Business and Professions
Code): ADDRESS Rt•t• °
❑ I, as owner of the property, or my employees with wages ;'i 7 't5oh{
='=
as their sale compensation, will do-the work and the CITY TEL.NO. _
structure is not intended or offered for sale (Section 7044, i I EN—
Business and Professions Code). OWNERZI /,/ ry 0 1 AL 45 - 00.
❑ MAIL
I, as owner of the property, am exclusively contracting �/ !V E` 3
with licensed contractors to construct the project (Sec- ADDRESSECC
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CIN r TEL.NO. O?d CHANGE
GE �-
I her
eby affirm that there is a construction lending agency for CONTRACTOR oil.the performance of the work for which this permit Is issued i
(Sec.3097,Civ.CJ ('.
Lender's NamADDRESS � /� j ,��l�il—�I(,I:�j / ai•�:•�
e �"+ i `•''''
CITY �ti TEL.NO. Q f? L 1'`i i i
J
Lender's Address STATE LIC.
I certify that I have read this application and state that the above LICENSE NO. CLASS C
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
property for inspect' In rp7es. SEE REVERSE FOR EXPLANATORY LANGUAGE
r
SIGNATURE OF APPLICA R AGENT DATE