HomeMy Public PortalAbout9933 LOWER AZUSA RD_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that i have a certificate of consent to sell
�i or fa ce ficote of Workers' , nsation Insurance/ 7GA364C HEATING - VENTILATING - AIR CONDITIONING
iie c d7i tl (!'ff
Po NO (/ Company Q 1,)/ W DPW 9/88
❑ Certified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
Cert fi co y is fled wit4cobuilding ins BUILDINGpart tFOR APPLICANT TO FILL IN ADDRESS
(PRINT OR TYPE ONLY)ApplicaLOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEEEXEMPTORKERS' NEARESTCOMPENSATIOCROSS ST
(This section need not be wmpleted If the work involved by ABSORPTION UNIT, BTU DISTRICTNO
PROCESSED BY
the permit Is for one hundred dollars($100)or less.) p
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM 5
permit is issued, I shall not employ any person in any manner BOILER BTU
so as to become subject to the Workers'Compensation Laws APPROVALS DATE INSPECTOR S SIGNATURE
Date Applicant COMPRESSOR, BTU O 1 ROUGH ��- O FAL
NOTICE TO APPLICANT If, after making this Certificate of VENTILATION SYSTEM FINAL a5/
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with compI 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
USPENDED UNIT_(commencing with Section 7000)of Division 3 of the Business WALL
and Professions and my license is in full for ardpffect T/i //
License Num Lic Class
G V >_
Contractor Date el Tc w I ,� 0
❑ I am exempt under Sec ACCT-* O
Plan check fee 33G7 bg-
B 8P C for this reason PERMIT ISSUING FEE $ 1 ITEMa z
Date
Signature TOTAL FEE / T01 AL 69 .00
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT CWCK 69-Q.
I hereby affirm that I am exempt from the Contractor's License ,
Law for the following reason (Section 7031 5, Business and NAME CKANE W
Professions Code)
❑ I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and CITY TEL NO U -�1 9/ b/ l
the structure is not intended or offered for sale(Section
7044, Business and Professions Code) OWNER 2729 1 All 8:11
❑ 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
Lender's Name
CITY ;�/ TEL NO
Lender's Address
I certify that I have read this application and state that the STATES UCLCASS
above information is correct I agree to comply with all County uaNsE
nces and State laws rel in to building construction,
ASignature
by authorize r pre t es of this Cou to ter
t aboverme ti ed for insSEE REVERSE FOR EXPLANATORY LANGUAGE
licant or Agent ®t