HomeMy Public PortalAbout6243 MUSCATEL AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION A P P U CAT I®IN FOR PERMIT
'I hereby affirm that I have o certificate of consent to self � �
insure; br dcertificate of Workers' CompUnsgtion insurance, , HEATING VENTILATINGAlit CONDITIONING
,or 6 certified copy thereof(Sec. 3800, tab. C.) 76A364C
20-0046 DPW 9/88
Policy No. Company
❑ Cer,)ified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. (PRINT OR TYPE ONLY) ADDRESS
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' I NEAREST
COMPENSATION INSURANCE CROSS ST.
ABSORPTION UNIT, BTU DISTRICT NO. PROCES D Y
(This section need not be completed if the work involved by „/
,4
the permit is for one hundred dollars ($100) or less.) AIR HANDLING UNIT, CFM (J}(
I certify that in the performance of the work for which this 5, 6
permit is issued, I shall not employ any erson in a manner
so as to become subject to the Worker Compen on ws. BOILER, BTU APPROVALS ATE INSPECTOR'S SIGNATURE
QA= ( COMPRESSOR, BTU 0 ROUGH
Date 149' 0 Applicant
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL f i
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATI
with comply with such provisions or this permit shall be deem-
ed revoked. FLOOR CE: FAU BTU GRAVITY
LICENSED CONTRACTORS DECLARATION
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 WA
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and Professions Co e,andmy I' ense is in full for and effect. }
CL
License Number : 'Lic. Class l V U
Contracto Date D
o- ® o
❑ I am exempt under Sec. V
Plan check fee W
IL
B.BP.C. for this reason PERMIT ISSUING FEE $ a
Date: z
TOTAL FEE
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License
Low for the following reason (Section 7031.5, Business and NAME
Professions Code): ;
❑ I, as owner of the property, or my employees with
ADDRESS
wages as their sole compensation,will do the work and l i a v
CI
the structure is not intended or offered for sale(Section N TEL. NO. r-',
7044, Business and Professions Code). OWNER t1'� iJ aLEL
❑ I, as owner of the property, am exclusively contracting 1 T T ENL
with licensed contractors to construct the project (Sec- MAIL
ADDRESS `�� G� 3
tion 7044, Business and Professions Code). TOTAL �,�a 00
CONSTRUCTION LENDING AGENCY CITYi a/ TEL.
I hereby affirm that there is a construction lending agency for L ',�IEtr i --°1=11
the performance of the work for which this permit is issued CONTRACTOR HANIGE ['r'
(Sec. 3097, Civ. C.).
t t`t
ADDRESS r
Lender's Name
CITY �� TEL. NO. j,{r „ �� i llcr-1-3001 ,/,,01sT_
Lender's Address
I certify that I have read this application and state that the STATE lCENSE NO. CLASS o'-�-� 1 Ar °i'
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and he by authonz re re ntatives of this County to enter
upon a above-me I ropefty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signature of Applicant or Agent Date @