HomeMy Public PortalAbout9923 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 certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a r fief jpp��a($gb�, Ib. C. 76A36aC
'�G (J ,t,T 20-0046-DPW 9/88
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Certified copy is hereby-furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy.is filed wit unty building i FOR APPLICANT TO FILL IN BUILDING C 2
•t n epartment. ADDRESS J
(PRINT.OR TYPE ONLY)" .
9 72 1 A,I
Appl i cant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF'EXEMPTION FR WORKERS' NEAREST
COMPENSATION INSURANCE 0o _ CROSS ST.
(This section need not be completed if the UNIT, BTU the work Involved by DlsrRlcT No. PROCESSED BY
the permit is for one hundred dollars (;100)or less.) AIR HANDLING UNIT, Cl O /%/
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 become subject to the Workers'Compensation Laws. BOILER, BTU /'� APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant COMPRESSOR, BTU oA" I ROUGH F4ntb
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINALV10-ay-91 I
Exemption, you should become subject to the Workers'
Compensation provisions of the:Lobor,.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 off irm 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.
yD
License Numbe Lic. Class_ ► 0
Contractor Date O
❑ I am exempt under Sec. V
Plan check fee U,
B.BP.C. for this reason a.
PERMIT ISSUING FEE $ ACCT. z
Date: _
Signature TOTAL FEE 6 3Q7 69.00
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 1 ITEMS
I hereby affirm that I am exempt from the.Contractor's License
Law for the following reason .(Section 7031.5, Business and NAME , TOTAL 69-0113
Professions Code): "
Q1, as owner of the property, or my employees with ADDRESS CKCK 69.W
wages as their sole compensation,will do the work and CITY TEL. NO. CHANE. aLN.I
the structure is not intended or offered for sale(Section
7044, Business and Professions Code). OWNER
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL 000G 71 9/ 6/90
tion 7044, Business and Professions Code). ' ADDRESS8:0
+ 724 1 AM 9
CONSTRUCTION LENDING AGENCY CITY TEL. NO. t L
I hereby affirm that there is a construction lending agency for ►
the performance of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.).-
ADDRESS S _
Lender's Name - .
CI �`� TEL. NO �-�
Lender's Address '
I certifythat I have read this application and state that the STATE LIC'
PP LICENSE N CLASS
above information is correct. I agree to comply with all County
ordinances and State laws elating to building construction,
an reby autfioriz e e olivae of this unty to enter
ii n e above. t"` a perty for P tion urposes. '
RY
SEE REVERSE FOR EXPLANATOLANGUAGE16,
.
Signotu f Applicant or Agent Date ®s