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HomeMy Public PortalAbout10163 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 coy thereof (Sec. 3800, Lab. C.) 76A364C ? CE-818(REV. 10/81) y©Policy No. Company COUNTY OF LOS ANGELES BUILDING AND SAFETY Certified copy is hereby furnished. ❑ Certified copy is filed with the co ty it ng i spec- FOR APPLICANT TO FILL IN BUILDING 110 do ADDRESS O , departm t. (PRINT OR TYPE ONLY) ^� LOCALITY Date y Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE _ ( CCC III CE IFICA OF EXEMPTIO W ERS' NEAREST C MPENSATION INSURANCE CROSS ST. A ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY (This section 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 thisi t/ O permit is issued, I shall not employ any person in any manner so as To become subject to the Workers'Compensation Laws. BOILER, BTU APPROVALS DATE SP TOR'S SIGNATURE Date Applicant / COMPRESSOR,.BTU 491 ®Q� v�( v/�� 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 VALIDATION with comply with such provisions or this permit shall be deemed revoked. FURNACE: FAUG T i1`J LICENSED CONTRACTORS DECLARATION FLOOR BTU ,( � (f(f I hereby affirm that I am licensed under provisions of Chapter 9HEATER: SUSPENDED -UNIT (commencing with Section 7000) of Division 3 of the Business WALL and Professions Code,and my9license is in full force and effect. License Number -,� Lic. Class G_ u Poo. 0 ContractorLY/T 6&4Date ( O U I am exempt under Sec... LU Plan check fee CL B.&P.C. for this reason 0z Date: PERMIT ISSUING FEE $ 0� 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, 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). . Ir �YV OWNER ❑ I, as owner of the property, am exclusively contracting ,��/ with licensed contractors to construct the project (Sec- MAIL ADDRES S ,J� / tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY NW NO. ��J I hereby affirm that there is a construction lending agency for R the performance of the work for which this permit is issued CONTRACTOR � St4 l (Sec. 3097, Civ. C.). yA ADDRESS JY� Lender's Name CITY t TEL. NO. Lender's Address STATE 14LIC. 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 a d State laws relating to building construction, and hereAy a t rize representatives of this County to enter upon th bo me iohed p operty for insp ction urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE SignaantorAg t e f pl 14