HomeMy Public PortalAbout10118 NADINE ST_Mechanical__ WORKERS COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that_I have a certificate of consent to self
or ainsurca or
copy thereof e of (Secars 38b0,-Lob
Insurance, 76A364C HEATING - VENTILATING - AIR CONDITIONING
Po cy No v).29G S7 Company • w. `°• 2D 0046 DPW 9/88
Certified 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 , O /
tion department ADDRESS / y
(PRINT OR TYPE ONLY)
Date 1-11— Applicant NO TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST
COMPENSATION INSURANCE CROSS ST
(This section noel not be completed If the work Involved by ABSORPTION UNIT BTU DISTRICT NO PROLE BY
the permit For one hundred dollars or less)
I certify thatt work
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
so as to become subject to the Workers Compensation laws BOILER BTU APPROVALS DATE INSPECTORS 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 VA I 16A CW V
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 SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business HEATER WALL
and Professions Code,and my license is in full force and effect /D ®Q
r M
License Number ` Lic Class 8 I Doo / E4 , u
Contractor&611 ate
❑ 0
~!I am exempt under Sec t
Plan check fee W
+ B 8P C for this reason Date PERMIT ISSUING FEE $ 0 z
Signature TOTAL FEE Q
OWNER BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that 1 am exempt from the Contractor s License ►
Law for the following reason (Section 7031 5, Business and NAME
Professions Code)
El 1, as owner of the property or my employees with ADDRESS AGGT■*
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section CITY TEL NO 3307 20.5 j
7044, Business and Professions Code) OWNER 1 ITEMS
❑ I,as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec AMAIL
DDRESS TOTAL ��
tion 7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY CITY TEL NO CHECK 20.511
1 hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTOR , C .00
(Sec 3097 Civ C)
ADDRESS
Lender's Name
2
CITY TEL NO
0000-0 l 12/ 4 BF
-f is
Lender s Address STATE LIC a !722 1 AM 8:52
I certify that I have read this application and state that the LICENSE NO CLASS i
ob9ve information is correct I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
u on the above-mentioned property for inspection purposes
fiA -n� SEE REVERSE FOR EXPLANATORY LANGUAGE
ignoture al Appli nt or Agent Date�/ i ®s