HomeMy Public PortalAbout9453 LONGDEN AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self
insure, or a.certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or o certified co y thereof y (Sec. 3800, C.) 76A364C
Policy No.� "�mpany �i JAJO 2o-o046 DPW 9/88
❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
--telrtlfled copy is filed with the o.unty build' inspec- I FOR APPLICANT TO FILL IN BUILDING fft
}Ion department. I ADDRESS
A �/l1 (PRINT OR TYPE ONLY)
Date r Applicant LOCALITY
FNO. TYPE OF APPLIANCE OR EQUIPMENT FEECERTIFICATE OF EXEMPTION FROM WORKERS' NEARESTCOMPENSATION INSURANCE CROSS ST.
(This section need not be completed if the work Involved byABSORPTION UNIT, BTU DISTRICT NO. PROCES BY
the 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
permit is issued, I shall not employ any peperr in any manner BOILER, BTU
so as to become subject to=ant—
NOTId
mpensation Laws. APPROVALS ATE INSPECT 'S SIGNATURE
Date A COMPRESSOR, BTU , ROUGH
TO APPLI : If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, yo s ould become subject to the Workers'
Compensa' provisions of the Labor Code,you must forth- EVAPORATIVE COOLER V L ATj ON
with-co Iyy with such provisions or this,permit shall be deem-
ed ravbked. FURNACE:
FAU BTU RAVITY
:7 Fi�
LICENSED CONTRACTORS DECLARATION (j
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.
CL
License Number anp Lic. Class , U
Contractor aIPyA110Cb Date — � C9
❑ • I am exempt under Sec. U
Plan check fee lu,
e.&P.C. for this reason CL
PERMIT ISSUING FEE $ W
Date: �
TOTAL FEE
Signature
' 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
Professions Code): '=
❑ 1,7 as owner of the property, or my employees with ADDRESS ACCTes
wages as their sole compensation,will do the work and CITY TEL. NO. i
the structure is not intended or offered for sale(Section 33137 ,3r aI 30
7044, Business and Professions Code).
❑ OWNER., I 11EMS
I,as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL ADDRESS TOTAL 37.00
s, tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY I TEL. NO. CHECK 37.011
1 hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTOR , CHANGE °'s
�
(Sec. 3097, Civ. C.).
ADDRESS '
Lender's Name CITY TEL.NO. 0000-0001 2/ 9/010
. q
Lenders Address STATE LIC. 83859 1 AM 10:28
I,certify'that,l have read this application and state that the LICENSE NO. CLASS
above 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 t ab a-me vtied p p for' section purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date