HomeMy Public PortalAbout9834 LONGDEN AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self
insure,,i p certificate of Workers' Compensation Insurance, HATING - VENTILATING - AIR CONDITIONING
oi'a certified copy tzhere f (Sec. 38 ab. C�.)/� � 76A364C
Policy No / /vs Compan uwG /20-0046 DPW 9/88
❑ Certified copy is hereby furnish d. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified cwpy is filed with the count building inspec- FOR APPLICANT TO FILL IN BUILDING � 3 L
ti/dep rtment. (PRINT OR TYPE ONLY) ADDRESS DJ G
Date Applicant- LOCALITY r
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTIO FROM W ERS' NEAREST
COMPENSATION INSURANCE CROSS ST. -✓
(This section need not be completed If the work involved by ABSORPTION UNIT, BTU DISTRICT NOPROCESSEPAY
the permit Is for one hundred dollars ($100)or less.) ( Q
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. JBOILER, BTU APPROVALS DATEI PE OR'S SIGNATU
Date Applicant COMPRESSOR, BTU a 006 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 if A I In Alffoh
with comply with such provisions or this permit shall be deem-
ed revoked. FURNACE: FAU GRAVIT
LICENSED CONTRACTORS DECLARATION FLOOR BTU /o .�= U
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 ® ® d
Contra Date oe
Elm aexempt u r Sec. O
Plan check fee W
B.&P.C, for this reason n.
PERARIT ISSUING FEE $ /D
_Z3 V)
Date: Z
Signature TOTAL FEE1301 -S—(�
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):
I, as owner of the property, or my employees with ADDRESS A
wages as their sole compensation,will do the work and RCCLU
the structure is not intended or offered for sale(Section CITY TEL. NO.OWNER 3-0?
F17044, Business and Professions Code). 30.50 I, as owner of the property, am exclusively contracting 1 ITU-133
with licensed contractors to construct the project (Sec- MAIL
�1.1�}
ADDRESS Q 1
tion 7044, Business and Professions Code). ` 0ZM11
CONSTRUCTION LENDING AGENCY CITY TEL. NO. ��i�IV 30.511
1 hereby affirm that there is a construction lending agency for �7
the performance of the work for which this permit is issued CONTRACTOR ® MANE o1010
(Sec. 3097, Civ. C.).
ADDRESS/,
Lender's Name ONO-= 8/16/89
Lender's AddressCITY / TEL. NO. 5
ATE LIC. �' 1J-
i 1 rj 1 N1 11 5
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1 certify that I have read this application and state that the LICENSE NO. p ��S / 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
upona ov, entioned property for i P;7n purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Sig at a cf Applicant Agent Dat