HomeMy Public PortalAbout9592 LOWER AZUSA RD_Mechanical__ DECLARATI
WORKER SCOMPENSATION
ate of consent to 7SM4BDPW9fe9 APPLICATION FOR PERMIT L�MV E GREEM
I hereby affirm tJiat I have a certificate of consent to self insure 78A384C
or a certificate of Worker s Compensation Insurance or a certified HEATING-VENTILATING AIR CONDITIONING
copy thereof(Sec 3800 Lab C) u
Policy No Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
El Certified copy Is hereby furnished
❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDINGjr
department (PRINT OR TYPE ONLY) ADDRESS p2 �011JFiff? /7 (fid/S7
Date ApplicantLOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST
CROSS ST
COMPENSATION INSURANCE
ABSORPTION UNIT BTU ASSESSOR
(Thls section need not be completed If the work Involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less) AIR HANDLING UNIT CFM
DISTRICT NO PROCESSED BY
I certify that In the performance of the work for which this permit
Is Issued I shall not employ any person In any manner so as to BOILER BTU
become subject to the Workers Compensation Laws a (/
COMPRESSOR BTU
APPROVALS DATE 1 S SIGNATURE
Data�i 919-!2 scant VENTILATION SYSTEM
NOTICE TO APPLICANT If aft making this Certificate of ROUGH
Exemption you should become subject to the Workers Compensation EVAPORATIVE COOLER
provisions of the Labor Code you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked FURNACE FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and WALL
Professions Code and my license is In full force and effect
License Number 848 3 3 3 Llc Classes'
v
Contractor Lr'VFr2"& COA115 Date
I am exempt under Sec❑ 2 ACCT.10 U
Plan check fee � 33063 -r� �I�
B&P C for this reason PERMIT ISSUING FEE$ O
I ITEMS 0
Date TOTAL FEE Q
I UTAL 39 ®00 IL
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT CHECK 39 a 0r,Z
I hereby affirm that I am exempt from the Contractors License Law NAME 01. � �UE 1 �
for the following reason(Section 7031 5 Business and Professions
Code) ADDRESS
❑ 1 as owner of the property or my employees with wages WOO
tri�tr--''(r'-,�
as their sole compensation will do the work and the CITY TEL NO 4.lVOO-0001 2f 91'F
structure is not Intended or offered for sale(Section 7044 1� i C
Business and Professions Code) OWNER 7a1r,9 t r M 122-m 04
❑ I as owner of the property am exclusively contracting MAIL
with licensed contractors to construct the project (Sec ADDRESS
tion 7044 Business and Professions Code)
CITY TEL NO
CONSTRUCTION LENDING AGENCY
I herp
eby affirm that there is a construction lending agency for CONTRACTOR � eQ/V TCTlalll 000.the performance of the work for which this perm s issued 4-r-yRS
(Sec 3097 Civ C)
ADDRESS s- l 6A t-ri U S A �01
Lender s Name
CITY TEL NO gf S `t-`o— o0
Lender s Address STATE LIC
I certify that I have read this application and state that the above LICENSE NO 6 418 333 CLASS
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 SEE REVERSE FOR EXPLANATORY LANGUAGE
2 Q
SIO AP LICANT OR AGENT DATE