HomeMy Public PortalAbout10635 LOWER AZUSA RD_Mechanical__ WORKERS'"COMPENSATION DECLARATION
.hereby'affirm that-I.hcve.a certificate of consent to self APPLICATION FOR' 'P.ERIUIIT:: .
insure, or a certificate of Workers'Compensation Insurance,:: ; .HEA-TING:,--.:VENTILATING = AIR, COIdDITION'fNG.
.. ( .0 76A364C - .. x a. . .. - -. .
Polic No. ej LQ3� C'Sec: 3800 Lab CE'-,818(REV.. IOx81)
or a,certified°,copy thereof
Y. ompany C " ('
Certified'-copy ishereby'furnished ��
LINTY OF LOS=ANGELES` BUILD,ING AND'SAFETY
Cer,tjfied•copy is'filea with th"e county building-i FOR•'APPLICANT`TO FILL.IN ." BUILDING" // r
1i,on de artment':° �C Olt1. US R
P , :• : (PRINT_OR TYPE ONLY)
ADDRESS 3
Date ' 2_ N Ap"plicant
' O:. "TYPE OF APPLIANCE OR EQUIPMENT'. FEE TY.r
- - LOCACI
COMPENSATION INSORANWORK
CERTIFICATE OF E.XEMPTION.FROMCE
,. ABSORPTION'UNIT BTU
NEAREST.
(This section need not be completed if the work'involved by,
" ROSS ST,
'' DISTRICT NO � PROCESSED. Y°
the permit-is`for one kundred"dollars-(5100)or less.) °'
I certify that in the performarice'^of the vvork,for which this
AIR HANDLING UNIT:CFM ci UY,
'Permit-:is'issued;"'I shall not employ any person in any-manner a� UUU
• ._- "' BOILER, BTU
' 'S0 a5 tO,beCOmerSU bje C1't0-the Workers'COmpen so BOILER, - - APPROVALS -.DATE - INS ECTOR'S SIGN TUBE
ROUGH C� .
Date Npp,licant /•
COMPRESSOR;,BTU
NOTICE TO.APPLICANT: Jf;'after-making'this Certificate of VENTILATION SYSTEM-
° Exemption you .'should'become'subject to the'.Workers'--
p p Y EVAPORATIVE COOLER
��
FINAL
'. with omplynw tkVsu�hs"p ovhstonas'orC h s;permit shall:be VALIDA ON
deemed.revoked. FURNACE:. -FAU GRAVITY
LICENSED CONTRACTORS.DECLARATION,- FLOOR. B 10
L, J
I.hereb affirm that I am.licensed-under ravisions,ofCha ter-9 SUSPENDED UNIT'
�J b
Y p. P ;. HEATER: WALL
(commencing,with`.Section 7000)'of Division 3 of theBusiness'
and Professions Code,and my license is in'fulLforce:and effect. O
,
License Number Tic Glass
1 940'A
?_�S
Contractor s e.2 Ct/Date "7.. ....
® �
oo ® g
I•am exempt underSec ' ` - 4 • d
Plan check fee> _ I o 2 4:5 0 y: ..
B:&P C forthls reason
Z.
PEFEE
PERMIT ISSUING"
Date:'
TOTAL FEE
Signature .. -, - . _
_ r 4.
' � 4 2`2 ,
OWNER-BUILDER.DECLARATION . PLAN CHECK APPLICANT z O, , 8'5
I hereby affirm that)am exempt from the Contractor's License
iaw"for the followln,g reason (Section 7031,.5, Business and- NAME
Professions-Code)-
i
"ADDRESS ,
❑, I, as owner of the'property, or;my employees with v
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 Rrofessions Code).
OWNER
1,
.'1, as owner of the property,=.am-exclusively contracting
' MAIL. - • :: �
with licensed contractors to construct the,project{Sec :,
tion 7.644, Business"dnd Professions ode).': - ADDRESS
CONSTRUCTION°LENDING AGENCY
CITY TEL NO''
1'herebyaffirrn that-there:is'a construction lending agency for
theperformnce of the`wok'for which this permit is issued- CONTRACTOR" '
(Sec. 3097 Cry .0,) � e
a
x ADDRESS'
a6
Lender's-Name ".
. w
.: CITYdTEL.AO.
Lender's-Address (> l � c
STATE,
I certify,that.I"hove'read this application and state that the . LICENSE-NO.-, :7 - =CLASS
above information is correct. I agree to comply.-with all County
ordinances`a'nd State laws relating Fo"building.construction,-
and hece.by out
r e tatives of-this County to enter
,u on: e above- ed Kroperty for inspection`purposes:. SEE REVERSE.FOR EXPLANATORY LANGUAGE :a z
4
-41
Signature-of App a t r A`geni .-,:'' .'Date •�" "