HomeMy Public PortalAbout9363 LOWER AZUSA RD_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT I
I hereby affirm that I have o,certificate of consent to self L�
insure, or a fertificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof(S 38 L b. ) ' MA364C
�/? 20.0046 DPW 9/86
Policy No'Ls � nY COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is hereby furnished.
,❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING .? > -
tion department. (PRINT OR TYPE ONLY) ADDRESS I (O
Date ApplicantLOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
ABSORPTION UNIT, BTU DISTRICT NO. PROCESS BY
(This sodlon need not be completed if the work involved by l
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 I
permit is issued, I shall not employ any person in any manner BOILER, BTU
so as to become subject to the Workers'Compensation Laws. APPROVALS ATE INSPECT R'S SIGNATURE
Date Applicant
COMPRESSOR, BTU �� �Q� bQ 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 _ �/ A
with comply with such provisions or this permit shall be deem-
ed revoked. FURNACE: FA /h GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU IIJJ
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
lkeense is in full force
and effect. 40 V D
1116
License Number
7r .'J �+Lic. Class912O
Contractor Date 0
O
❑ I am exempt under Sec V
Plan check fee W
B.BP.C. for this reason PERMIT ISSUING FEE $ 3 in
H
' Date: Z
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): S_ I
❑ I, as owner of the property, or my employees with ADDRESS ACCT J0
wages as their sole compensation,will do the work and Cin, TEL NO.
the structure is not intended or offered for sale(Section `;07 1■1131
7044, Business and Professions Code). OWNER
I,as owner of the property,am exclusively contracting 1 ITEM
E]
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code). TTL' . e 1
CONSTRUCTION LENDING AGENCY CITYA0.4 TEL. NO. ,0, 2G WECK 1.01
I hereby affirm that there is a construction lending agency for faetv
the performance of the work for which this permit is issued CONTRACTOR l6 P ® .00
(Sec. 3097, Civ.C.). 3 p
ADDRESS n /1 n n�i�n�n c �t''en
Lender's Name CITY.fY./fes �,�, TEL,NO. �pG� 00M_OM1 V 1 7Cr
Lenders Address e
1 certifythat I have read this application and state that the STATE LIC. f7 ��j 1 ( : 7
pp LICENSE NO. 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 q pLa1prty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date
9s