HomeMy Public PortalAbout9361 LOWER AZUSA RD_Mechanical__ WORKERS'COMPENSATION DECLARATION APPUCATION FOR PERMIT
I hereby affirm that I have q certificate of consent to self
insure, or a certificate-of Workers' Compensation Insurance,
or a certified copy thereof (Set 38 , L b. ) 7/YA364C MUM - VENUILATING - AIR CONDITIONING
Policy No.
/�CWh any_ 20-0046 DPW 9/88
• �'•�
❑ 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
}ion department. ADDRESS & f a
(PRINT OR TYPE ONLY)
Date Applicant LOCALITY 4
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESS 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
permit is issued, I shall not employ any person in any manner BOILER, BTU r
so as to become subject to the Workers'Compensation Laws. / APPROVALS ATE INSPECT R•S SIGNATURE
Date Applicant COMPRESSOR, BTU �'� AA 00 ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers' fv
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER V bilkJAI with comply with such provisions or this permit shall be deem-
ed revoked. FURNAFLOOR CE. FA B7UD GRAVITY 6()LICENSED CONTRACTORS DECLARATION
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. / t - 00
License Number , Lic. Class ceC ,- CL
V
Contractor l Date Y717A— /G�® ad
❑ I am exempt under Sec. u
Pian check fee w
B.&P.C. for this reason `� �n CL
PERMIT ISSUING FEE $ CW W
Date:
Signature TOTAL FEE
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 NAMEob V C
Professions Code):
❑ I, as owner of the property, or my employees with ADDRESS op '3 ^
. - r
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section CITYdATEL. NO. ..7X
7044, Business and Professions Code). OWNER r.
F-1 1,I, as owner of the property, am exclusively contracting I
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS / f ,+ 1p:L
CONSTRUCTION LENDING AGENCY CITY TEL. NO. D �� i'}{ i{7t iaCli
I hereby affirm that there is a construction lending agency for •y
the performance of the work for which this permit is issued CONTRACTOR Q f' H"j(;E niJl_I
(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name �'� ¢� +�'•rrz- r• i1 5/ l/'�L
CITY TEL. NO. Gc-�i��r tJt1s ILl'tlt
Lender's Address
I certifythat I have read this application and state that the STATE LIC. I,'24 1 i" Z U.49
PP LICENSE NO. L 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
n t ab v ntio pro rty for inspection purposes.
`90
+ SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date