HomeMy Public PortalAbout9931 LOWER AZUSA RD_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that i have a certificate of consent to self
Insyy�{e, or a certificate of Workers'Compensation Insurance,
a�aye0fl p�ttg76 (18DO a ) , 76A364c HEATING - VENTILATING - AIR CONDITIONING Rb
PoI1/cy o Company j(J 40-0046 DPW 9/88
Certified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
�Certifled copy is filed with;;WORKERS'
ry building I - FOR APPLICANT TO FILL IN BUILDIN
n e ment ^ ADDRESS
ool (PRINT OR TYPE ONLY)
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Date` Applicant LOCALITY
O TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION NEAREST
COMPENSATION INSURANCE CROSS ST
(This section need not be completed If the work Involved by ABSORPTION UNIT, BTU DISTRICT NO 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 O „/
so as to become subject to the Workers'Compensation Laws BOILER, BTU APPROVALS DATE INSPECTOR S SIGNATURE
Date Applicant
COMPRESSOR, BTU ROUGH =,2-910 �
NOTICE TO APPLICANT If, after making this Certificate of VENTILATION SYSTEM FINAL a 9
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with compIy with such provisions or this permit shall be deem-
ed revokedy FURNACE FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED UNIT—
(commencing
NIT_(commencing with Section 7000)of Division 3 of the Business WALL
and Professions Code,and my license is in full fo and effect
�Z0
License Number Llc Class-� //+� T / 0 Z >V Pool
Contracto + Date —9J 4 Tgsou 11e4J 00,
a 0
El am exempt under Sec AUTaT
Plan check fee
B&P C for this reason PERMIT ISSUING FEE 3 W 69.10
Dare TOTAL FEE � 1 ITEM Z
Signature TOTAL 69.00
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
1 hereby affirm that I am exempt from the Contractor's License , CWCK 69.01
Law for the following reason (Section 7031 5, Business and NAME I
Professions Code) .00
❑ 1, as owner of the property, or my employees with ADDRESS--
wages as their sole compensation,will do the work and
the structure Is not intended or offered for sale(Section CITY TEL NO 1 9/ 6/%
7044, Business and Professions Code)
F1 1, 2727 1 API $:10
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
(Sec 3097, Civ C)
ADDRESS 60a. U
Lender's Name
CITY1 TEL NO 2–4
Lender's Address
I cern that I have read this application and state that the STATE UC /�fL?7
certify PP LICENSE CLASS C_ C./
above Information is correct I agree to comply with all County
ordinances and State laws relating to b Ilding construction,
reby authorize representatives h ounry to enter
'Iqpon e above-Wren io property r tion purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Sig re plicant or Agent Date
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