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HomeMy Public PortalAbout9521 LAS TUNAS DR_Mechanical__ WORKERS'COMPENSATION DECLARATION �` t �/��►P� �ICATION FOR PERMIT I hereby affirm that I have a certificate of consent to self insu*e; or-a Certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING or a certified copy thereof Sec. 3800, Lab. C.) 76A364C 1, v CE-818(REV. 10/81) Policy NoLW'7f1t7 Company _5 Fowl ® 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 9s �► I ��s 7L�/d//3S .l�f-�r9v' tion eportmeent. (PRINT OR TYPE ONLY) ADDRESS Date-71 31 o Applicant LOCALITY ` r� NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST I`/� R COMPENSATION:INSURANCE CROSS ST. (This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY the permit is for one hundred dollars ($100)or less.) AIR HANDLING UNIT, CFM I certify that in the performance of the work for which this ✓_t C/ permit is issued, 1 shall not employ any person in any manner BOILER, BTU so as to become subject to'the Workers'Compensation Laws. APPROVALS DATE INSP OR'S SIGNA RE Date Applicant COMPRESSOR, BTU 6 D cc© ROUGH / � � 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 VALIDATtKN with comply with such provisions'or this permit shall be deemed revoked. FURNACE: FAUGRAVITY' LICENSED CONTRACTORS DECLARATION FLOOR BTU /00 Off: 0()- I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED—UNIT— '(commencing USPENDED UNIT'(commencing with Section 7000) of Division 3 of the Business WALL and Professions Code,and my license is in full force and effect. >. License Number `� Lic. Class x P1111. (0) 'Pit H-,3 e q+r"N u ` �i7 ad Contractor 4 C-oo.(o A'" '�R+' Date O, 3 ❑ U 1 am exempt under Sec. � Plan check fee a N B.&P.C. for this reason PERMIT ISSUING FEE $ Dat Signature r`P �� c� � TOTAL FEE ;P757,8A OWNER-BUILDER DECLARATION �— PLAN CHECK APPLICANT 1 hereby affirm that I am exempt from the.Contractor's License n #'o 0 0 0'0 Law for the following reason (Section 7031.5, Business and NAME Professions Code): o.- 3050 ❑ ADDRESS C, I, as owner of the property, or my employees with / S� 7vNA S o 0 0 3 0 5 0 v wages as their sole compensation,will do the work and t .r� the structure is not intended or offered for sale(Section CITY 7-2�✓'f�'°�P If r 7e TEL. NOof 8--S' E13 S-- 'o 7,31 .:8 7 7044, Business and Professions Code). OWNER Sq j/LS®t/•� ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec- MAIL tion 7044, Business and Professions Code). ADDRESS �/t/L! n'� ✓� CONSTRUCTION LENDING AGENCY CITY TEL. NO. I hereby affirm that there is a construction lending agency for. , t(Sec. 3097, Civ. C.).he performance of the work for which this permit is issued CONTRACTOR App 7""4/& C"O/6"416 ADDRESS Lender's Name CITY ROS EJJ/�if p�(�( TEL. NO.STATE Lender's Address r� ' I I certify that I have read this application and state that the LICENSE NO. -G_ a S7 CLASS F• above information is correct. I agree to comply with all County ordinances and State laws relating to building construction, I and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Applicant or Agent Date "'