HomeMy Public PortalAbout9521 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 certiiicdf'e of Workeig' Comppnsatjon Insurance,
or a certified copy thereof (Sec. 3804 La`b. C.) 76A364C HEATING - !VENTILATING - AIR CONDITIONING
20-0046 DPW 9/88
Policy No. Company
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Conlded copy is filed with the county building inspec- FOR APPLICANT TO FILL IN ADDRESS C)5--Z/BUILDING LOG✓5 AL'GlS11 t/�
(PRINT OR TYPE ONLY) '
Date Applicant LOCALITY CI?l b 7_Z7/-/ E C17-.V
NO. ' TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST ,{
COMPENSATION INSURANCE CROSS ST. F/ES-77,,4 74V'
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PR Y
the permit is for one hundred dollars(;100)or less.) Al. 069A
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
so as to become subject to the Workers'Compensation Laws. BOILER, BTU APPROVALS DATE NSPECTOR'S_9 NATURE
Date Applicant COMPRESSOR, BTU ( Z 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 VA IDA I N
withcomp with such provisions or this permit shall be deem-
ed revoked. FLOOR CE: FAU BTU G
LICENSED CONTRACTORS DECLARATION
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 license is in full force and effect. /
of ,l'j d
License Number Lic. Class , O
U
Contractor Date ad
0
IDI am exempt under Sec. O
Plan check fee U
W
B.&P.C. for this reason3 �, CL
Date: PERMIT ISSUING FEE $ W
TOTAL FEE
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 576(;/e S j! I fL&t 3'O�
1 hereby affirm that I am exempt from the Contractor's License ►
Law for the following reason (Section 7031.5, Business and NAME
Professions Code): L
I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and ACCT■7
the structure is not intended or offered for sale(Section CIN� O/if`�/P�� �yPcK TEL. N0�OC60 ��Z
7044, Business and Professions Code). �`�I�� t ■1=1�
I, as owner of the property, am exclusively contracting OWNER _ i ITEMS
with licensed contractors to construct the project (Sec- ADDRESS L
tion 7044, Business and Professions Code). TOTAL 73. 00
CONSTRUCTION LENDING AGENCY CITY S• r� C TE o . ¢9- d' 99� CHE F► 7. o
I hereby affirm that there is a construction lending agency for f -j'■ tl
the performance of the work for which this permit is issued CONTRACTORQWA/,Z:& �jG/�Lb�� j CHANGE ■I�!]
(Sec. 3097, Civ. C.). I
ADDRES
Lender's Name
CITY TEL.NO. 2/910
Lender's Address •-r
1 certifythat I have read this application and state that the STATE LIC. rC}/t!] 1 AM��vq
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
upon the above-mentioned property for inspection purposes.
J SEE REVERSE FOR EXPLANATORY LANGUAGE
SIg ure of 411cant or Ag Date @