HomeMy Public PortalAbout9929 LOWER AZUSA RD_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self
i rH, or a certificate of Work r' mpensotion Insurance, 76.3646 ance, HEATING - VENTILATING - AIR CONDITIONING
( �T '
20.0046 DPW 9/88
Policy No. Company
Certified copy is,hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified co y is filed ricounty build' g ' pe FOR APPLICANT TO FILL IN BUILDIN
epart ent. PA,0%J,,, A a
b!zusg
(PRINT OR TYPE ONLY) ADDRESS d14
Date " Applic nt LOCALITY
NO. TYPE,OF APPLIANCE OR EQUIPMENT FEE
ERTI ICATE OF EXEMPTION F6bM WORKERS' NEAREST
-COMPENSATION INSURANCE71:0,00CROSS ST.
ABSORPTION UNIT, BTU
(This section need not be completed if the'.work Involved by ABSORPTION PROCESSED BY
the permit is for one hundred dollars($100) or less.) ,
a' 1 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 o
BTU
so as to become subject to The Workers' Compensation Laws. BOILER, APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant COMPRESSOR, BTU ROUGH
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 C and m license is in full foyge and effect.. //��
License Num Lic. Class �� 0
u 1c 011111.
Contractor Gs Do _ ,� ) ( f� 4 O
0
EI am exempt under Sec. �V l!
Plan check fee
W
B.BP.C. for this reason /� v H
Date: PERMIT ISSUING FEE $ Z
Signature TOTAL FEE o ACCT.AT
OWNER-BUILDER DECLARATION PIAN CHECK APPLICANT 3347 69.00
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and NAME , 1 ITEMS �
Professions Code):
I, as owner of the property, or my employees with ADDRESS TOTAL 69 mf6��
wages as them sole compensation,will do the work and CITY TEL. NO. f HECry Q7.03
the structure is not intended or offered for sale(Section
7044, Business and Professions Code). OWNER GHANISE .011
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 OM—WO a f t/
CONSTRUCTION LENDING AGENCY CITY TEL. NO.. .M 7 v
QO
I hereby affirm that there is a construction lending agency for loop. 1 AM 8;10
the performance of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.).
ADDRESS f
Lender's Name
•CI TEL. NO.
Lender's Address
I certify that I have read this application and state that the ST CENSE NO CLASS
above information is correct. I agree to comply with all County
ordinances and State Id lating to buildin construction,
a hereby autho ' e r ntatives of is unt to enter
u n the aljsve- a ne r perty f i ctio urposes. SEE REVERSE,FOR EXPLANATORY LANGUAGE
Signa re of Applicant or Agent to ®s