HomeMy Public PortalAbout10159 LOWER AZUSA RD_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 a certified copy t reof (Sec. 3800 L b. C.) 76A364C
Policy No 3p Compan7UAJ-/)
CE-818(REV. 10/81)
,-2--Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the co nt b i g ins c- FOR APPLICANT TO FILL.IN BUILDING
ADDRESS
tion depart ent. / (PRINT OR TYPE ONLY) "
^f LOCALITY
Date / Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CER IFICAT OF EXEMPTIO ROM W ERS'
NEAREST
COMPENSATION INSURANC CROSS ST.
ABSORPTION UNIT, BTU DISTRICT NO.. PROCESSED.BY
(This secti n need not be completed if the work involved by
the permit is for one hundred dollars (;100)or less.)
AIR HANDLING UNIT, CFM
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. BOILER, BTU y APPROVALS DATE INSPE OR'S SIGNATURE
COMPRESSOR, BTU + w b ( (M ROUGH i ���. ' .
Date Applicant
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 VALIDAT ON
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRA ITY
LICENSED CONTRACTORS DECLARATION L 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.
License Number "�+ k3 Lic. Class �- V U
Ir
Controcto Date
t—
❑ I am exeml t under Sec. U
Plan check fee
a.
B.&P.C. for this reason 1
PERMIT ISSUING FEE $
Date:
TOTAL FEE I I-SOSignature
,r•;•-
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am'exempt from the Contractor's License DSI I{` I
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 CITY TEL. NO. 51
c �^
the structure is not intended or offered for sale(Section17
7044, Business and Professions Code). iM.3 'I
OWNER �v
I, as owner of the property, am exclusively contracting '•'
with licensed contractors to construct the project (Sec- MAILf
tion 7044, Business and Professions Code). ADDRESS 1 Iia:—Clf
CONSTRUCTION LENDING AGENCYCITY f Ell
L. NO. 3C E E != t �`+" >.
°
I hereby affirm that there is a construction lending agency forfilt °
the performance of the work for which this permit is issued CONTRACTOR ,
(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name
CITY TEL. NO.
Lender's Address
STATELIC. r
I certify that I have read this application and state that the LICENSE NO CLASS C�
above information is correct. I agree to comply with all County
ordinances nd State lFprese
s relating to building construction,
and her y orizentatives of this County to enter
upon t e abo men d pr perty for insp ctio purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
1
Sign Appli nt or Age //e