HomeMy Public PortalAbout9925 LOWER AZUSA RD_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self
insure, or aOr dc(,e�rtif%icate.�of/fr/W}'{porkers' ompensation�ylns�ur�an7c�2� 76A364c HEATING VENTILATING - AIR CONDITIONING
l W/ /'�If�C/ 20-0046 DPW 9/88
Polic Co.ICompany
❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with unty building in p FOR APPLICANT TO FILL IN BUILDING
"CERTIICATE
. ADDRESS
(PRINT OR-TYPE ONLY)DateApplicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEEF EXEMPTION FRO WORKERS' NEAREST
COMPENSATION INSURANCE _ CROSS ST.
(This section need.not be Co listed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY
the permit is for one hundredmpdollars($100) or less.) �� O
I certify that in the performance'of the work for which this AIR HANDLING UNIT, CFM
permit is issued,.l'sholI 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 4106 ROUGH _ _594PI
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'complYy 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 fort and effect.
F 2� _
License Num Lic. Class O T � �Flo 0
ContractorDate ^� `Tr/ P 0
❑ I am exempt under'Sec. ( (� +G y O
Plan check fee ,1 u
W
B.BP.C..for this reasona O.
PERMIT ISSUING FEE $ .13 Ar4CTAO z
Date: TOTAL FEE 3307 69:M
Signature � ,
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 69.00
Professions Code):
I, as owner of'the property, or my employees with ADDRESS— CHECK b9e�tl
F1
wages as their sole compensation,will do the work and CITY TEL. NO. CHAWGE 'W
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 IM-1 9/ 6/90
with licensed contractors to construct the project (Sec- MAIL h1
tion 7044, Business and Professions Code). ADDRESS 2775 ti�1 1 ll 8:09
CONSTRUCTION LENDING AGENCY CITY TEL. NO. L 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
Lender's Name ?,
CIr%,#JqJ6tgL TEL. NO�z 7J
Lender's Address � s
I certi that I have read this application and state that the STATE �c� UC.
. fY PP LICENSE NO.f. CLASS
above information is correct. I agree to comply withal.County
ordinances and State laws relating to building construction,
ecrrd-kereb authorize re s totives of this County to enter
on he above-me o party fo p ctio purposes.
- SEE REVERSE FOR EXPLANATORY.LANGUAGE
JAj
Signatur f Applicant or Agent Date ®y