HomeMy Public PortalAbout9921 LOWER AZUSA RD_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self
insure, or cicertificate of Workers' ompensotion Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a ifie pip S tb C.) 76A3
Polic ompany ..v✓ww
�/70XrDPW 9/88'
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❑ Certified copy-is hereby furnished.. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed witounty'building ' s FOR APPLICANT TO FILL IN BUILDING
ti n e tment 14 r (PRINT OR TYPE ONLY) ADDRESS
Date ApplicantIV"" LOCALITY
'/NO.... TYPE OF APPLIANCE OR•EQUIPMENT FEE
CER IFICATE OF•EXEMPTION FR WORKERS' NEAREST
COMPENSATION INSURANCE BTU 7�0�� CROSS ST.
(This section need not be comppleted if the work involved by ABSORPTION UNIT, NO.O. PROCESSED 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 v
BTU
so as to become subject to the Workers'COmpensotion LOWS.. BOILER, � APPROVALS. DATE INSPECTOR'S SIGNATURE
Date Applicant COMPRESSOR, BTU 'Clow !2 ROUGH /a- a
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 VALIDATION
with comp)y with such provisions or this permit shall be deem-
ed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
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.
_7 _ d
License Numbe Li . Clas� (/ , O
Contracto 'w ate Z
r �L T lll9 / u U
ty
ACCTeg O
❑ I am exempt under Sec. li-
Plan check fee 3307 69.1V
B.BP.C. for this reason PERMIT ISSUING FEE 1 ITEMS Z
Date:
Signature) TOTAL FEE TOTAL 69 . 00
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License , CHECK 69.00
Ldw for the following reason (Section 7031.5, Business and NAME CHANGE .'00
Professions Code):
' I; 'as owner of the property,,or my employees with ADDRESS
wages as their sole compensation,will do the work and CITY TEL. NO. 1000D-M1 9/ 6/90
the structure is not intended or offered for sale(Section
7044, Business and Professions Code). OWNER. 27t3 1 AM 8.808
❑ I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY TEL. NO.
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTOR Gle 14-1 d ,
(Sec. 3097, Civ. C.).
ADDRESS G
Lender's Name
CITEL. NO. 3
Lender's Address
I certify that I have read this application and state that the STATE UC.
LICENSE NO .-� CLASS
above information is correct. I agree to comply with all County
ordinances and State laws relating'to building construction,
hereby authorize rep sentatives of this ounty to enter
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above m io e' o erty for ' s tion urposes.. •
SEEREVERSEFOR EXPLANATORY LANGUAGE
SignaturfJf Applicant or gent to ®3