HomeMy Public PortalAbout9927 LOWER AZUSA RD_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affjrm..that I have a certificate of consent to self
insure, ora certiifffiica�tej�off Workers' Compensation Insurance, _ HEATING VENTILATING - AIR CONDITIONING
'IfyeocNllJ3800, C.) �T 720-0046 DPW 9/88
P Ii No. (�� /(J�Ccimpany
❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed withty building in FOR APPLICANT TO FILL IN BUILDING 71 � pA
ement. ADDRESS
pa
(PRINT OR TYPE ONLY)
Dote 90 Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FRO WORKERS' NEAREST
COMPENSATION INSURANCE' CROSS ST.
ABSORPTION UNIT, BTU
(This section need not be completed if the work Involved by D + DISTRICT NO. PROCESSED BY
the permit Is for one hundred dollars($100)or less.)
AIR HANDLING UNIT, CFM
'I certify that in the performance of the work for which this 5, U
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 00( ROUGH _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 comply 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 for a and effect.
SZ
.� d
License Numl�F)Cll �� Lic. CII ZO !� 1 O
Lam/ d ►
Contractor Date / O
❑ I am exempt under-Sec.-
Plan check fee
B.BP.C. for this reason H
' PERMIT ISSUING FEE $ LZ
-Date: ACC aF Z
Signature TOTAL FEE 33107 69.00'
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License ► i ITEMS
Law for the following reason (Section 7031.5, Business and NAME i . TI]TAL $ �E]
Professions Code):
❑ I, as-owner of the property, or my.employees with ADDRESS CHECK 69.W
wages as their sole compensation,will do the work and
the CITY TEL.:NO.structure is not intended or offered for sale(Section GF (GE .(XI
7044, Business and Professions Code). OWNER
❑ I, as owner of the property, am exclusively contracting rt�yr���-y�t�i
with licensed contractors to construct the project (Sec- MAIL a VVUV—VVtJl 7/ 6/90
tion 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY TEL. NO. 2726 I AM U:10
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
Lenders Name ] 2
CIN ` TEL..NO.I.S / L ✓�
Lender's Address
I certifythat I have read this a lication and state that the STATE UC. • ..
PP LICENSE N CLASS
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
hereby authorize repr tives of this County to enter
po the abovrg-me n rty for i n' n p poses. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signa, of Applicant or Agent Da ®s