HomeMy Public PortalAbout10155 LOWER AZUSA RD_Mechanical__ .`, WS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
• ( Fiereby-gfft`i-rm irm that•I have a certificate of consent to self '
insure, or 6 certificate of Workers' Compensation Insurance, HEAPING - VENTILATING - AIR CONDITIONING
or a certified dopy thereof (Sec. 3800, Lab.. C..)) FK
/� 76A364C"
$ /�/G /(iT.IVD
CE-818(REV. 10/81)
Poli No. Company
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 � L
tion department. g t (PRINT OR TYPE ONLY)
� ADDRESS
Date a Applicant LOCALITY ✓I ti
NO. TYPE OF APPLIANCE OR EQUIPMENT. FEE
CERT KATE OF EXEMPTION FRO WORKERS' NEAREST �7
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.)
I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM J f Y
permit is issued, I shall not employ any person in any manner BTU 111
so as to become subject-to the Workers'Compensation Laws. BOILER, APPROVALS DATE SR?CTOR'S SIG ATURE
Date Applicant COMPRESSOR, BTU rOt7� ) Z,� 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 VAI IDAT ON
with comply.with such provisions or this permit shall be
deemed revoked. FURNACE: FAU G VITY
LICENSED CONTRACTORS DECLARATION 4— FLOOR BTU )
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 , V
CK
��s�-4CQ-
Date
Contractor O
❑ I am exempt under Sec.
Plan check fee
B.&P.C. for this reason
Date: PERMIT ISSUING FEE $ 0 , 6; z
-
Signature TOTAL FEE 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
wages as their sole compensation,will do the work and '
the structure is not intended or offered for sale(Section CITY TEL. NO.
7044, Business and Professions Code).
OWNER OL
❑ I,"as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRES
CONSTRUCTION LENDING AGENCY CITYTEL. NO
If
I hereby affirm that there is a construction lending agency for ,
the performance of the work for which this permit is issued CONTRACTOR `
(Sec. 3097, Civ. C.).-
ADDRESS �- -•i -..! `i: J= !;.•.3 '`'
Lender's Name
CITY TEL. NO. V �V'r r '! :.2:: G• t
Lender's Address
STAT (C Q LIC. /�
I certify that I have read this application and state that the LICENSE NO. v Q, CLASS 6—'/0
above inform tion is correct. I agree to comply with all County
ordinances an tat laws rel ting to building construction, F!:!
and here au ri rey
lives of this County to enter P�
upon the bov e ioperty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE. r°
t otoSignot r y ttiFa !�� '• t"'t '�tT .