HomeMy Public PortalAbout9531 LONGDEN AVE_Mechanical__ WORKERS:COMPENSATION DECLARATION +
.'I hereby affirm that I have a certificate of consent.to self APPLICATION FOR PERMIT
insuck,,.or-'c.ceAificate.of Workers' Compensation Insurance; 76A364C HEATING - VENTILATING - AIR CONDITIONING
or a,certified copy thereof(Sec. 3800, Lab. C.) •20 0046 DPW 9/88
Policy No. Company
❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building inspec- BUILDING
tion department. FOR APPLICANT TO FILL IN ADDRESS
(PRINT OR TYPE ONLY) 1 G /_oAj(,rA5,3 Ave
Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST. 1 —
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED B
the permit is for one hundred dollars(5100)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 person in any manner ! `
so as to become subject to the Workers'Compensation Laws. BOILER, BTU APPROVAL DATE IN &OR'S SIGNATURE
Date Applicant COMPRESSOR, BTU ROUGH ^. F
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FIN
Exemption, you should become subject to the Workers'`
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER st ,p (1 VALIDATION
with comp)y 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 9SUSPE. UNIT—
(commencing with Section 7000)of Division 3 of the Business HEATER: WALL
and Professions Code,and rimy license is in full force and effect.
License Number' Lic. Class , 0
O
U
Contractor Date oG
❑ I am exempt under Sec. V
Plan check fee
B.&P.C. for this reason W
Date: PERMIT ISSUING FEE $ Z
Signature I'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
Professions Code): �a
I, as owner of the property, or my employees with ADDRESS t
wages as their sole compensation,wil I do the work and ACCT.e
the structure is not intended or offered for sale(Section CITY TEL.NO. 33 `}ael.'I
7044, Business and Professions Code).
I, as owner of the property, am exclusively contracting OWNER 1 ITEMS
with licensed contractors to construct the project (Sec- MAIL ���A�. ITEMS
.�,
tion 704.4, Business and Professions Code). ADDRESS m
00
CONSTRUCTION LENDING AGENCY TEL. NO. �Et ,cJeL)�I
I hereby affirm that there is a construction lending agency for CI LIE G T -TE 66 42
the performance of the work for which this permit is issued CONTRACTORtJ� , CHANGE
(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name
CITY TEL. NO. 5/22/90
Lender's Address
STATE LIC. 13835 1 fil'I :13
I certify that•I have read this application and state that the LICENSE NO. CLASS
above information is correct. I agree to comply with all County
ordinances State laws�re, ting to building construction,
and her uthorize reps atives of.this County to enter
upon abov me do dperty for insQection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
f'gnature of Applicant Agent Date