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HomeMy Public PortalAbout9565 LAS TUNAS DR_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT I hereby affirm that I have a certificate of consent to self nsure,-Ur a certificate of Workers' Cam p !station In surance, HEATING - VENTILATING - AIR CONDITIONING or a certifi d copy thereof ec. 800, Lab.'C.) 76A364C � y� (, YP 0 20-0046 DPW 9/88 Policy No. smP.� a I _ F1 Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY El Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING 9 S tion department. ADDRESS J (PRINT OR TYPE ONLY) Date Applicant LOCALITY ZL� I NO. TYPE OF APPLIANCE OR EQUIPMENT FEE (� CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. ABSORPTION UNIT, BTU DISTRICT NO. PROC D BY (This section need not be completed if the work involved by the permit is for one hundred dollars ($100) or less.) AIR HANDLING UNIT, CFM ot I certify that in the performance of the work for which this � permit is issued,,I shall not employ any p rson in any manner BOILER, BTU so as to become subject to the Worker ' ompensa' ri L �J rl Oaf ( APPROVALS DATE NSPE OR'S$iGNATURE Date~�y Or+ COMPRESSOR, BTU v U"" ROUGH NOTICE TO APPLICA T: If, er making thl Certificate of VENTILATION SYSTEM FINAL Exemption, you shuld come subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER � ID T O with comply with such provisions or this permit shall be deem- ed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU 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 WALL. and Professions Code,and my license is in full force and effect. voolo � Class—ML " License Number ar')A0 00S ntractor U 0 a' O qa am exempt under Sec. Plan check fee L, B.BP.C. for this reason. CL PERMIT ISSUING FEE $ ®0 Date: _ Signature TOTAL FEE OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and NAME J 2-0 ► Professions Code): 1, as owner of the property, or my employees with ADDRESS �� ��15 ro�� .- wages as their sole compensation,will do the work and / � �/t ACCT.4 the structure is not intended or offered for sale Section CITY /,�7 NO. /(q,{' y� ' 'r'$ 7044, Business and Professions Code). OWNER /S -� �W Ct . .5 a�/ //',• l� D -5�eq 53O:j1 1 I, as owner of the property, am exclusively contracting -,F#9 r/ TTEMS with licensed contractors to construct the project (Sec- MAIL 9 i I= tion 7044, Business and Professions Code). ADDRESS 12 ,6b �) 1 I �. CONSTRUCTION LENDING AGENCY CITY n !� JOEL. NOp ,7!'� Jui . 7 G I hereby affirm that there is a construction lending agency for , C;HECUK cL0 F ii_I the performance of the work for which this permit is issued CONTRACTOR — (Sec. 3097, Civ. C.). CHANGE311 ADDRESS Lender's Name CITY S TEL. NO J,6,0 ,yQ_V _ •3'� Lender's Address <' Q� /� ? 1 certify that I have read this application and state that the STATE ENSE NO. 3� cT C LA CSS-6 "o✓ ��i f� � ?` above information is correct. I agree to comply with all County a d'nan es and State laws relatin to Idin construction, and r by authorize re cese i e o This ounty to enter up e above-m ned o r r l ection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Sign plic t AgeNt Date ©s