HomeMy Public PortalAbout10122 NADINE ST_Mechanical__ WWWORKERS COMPENSATION DECLARATION APPLICATION FOR PERMIT
.reby affirm that I have a certificate of consent to self
insure or a certificate of Workers Compensation Insurance 7i5A364C HEATING VENTILATING AIR CONDITIONING
or a certified copy thereof(Sec 3800 Lab C )
O/ W� � f V Z 0 / CE 81 (REV 10/81)
Policy No ompony,, u t2fay,%o d. 41 9L4 tro c
Certified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building inspecFOR APPLICANT TO FILL IN BUILDING
tion department ADDRESS p1
_ (PRINT OR TYPE ONLY)
Date-1— L�`G Applicant w� /�S LOCALITY ._�
NO TYPE OF APPLIANCE OR EQUIPMENT FEE ew, Oe 45
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST
COMPENSATION INSURANCE CROSS ST Ara{ p
(This section need not be completed If the work involved by ABSORPTION UNIT BTU DISTRICT NO r PROCESSED BY
the permit is for one hundred dollars($100)or less) AIR HANDLING UNIT CFM
I certify that in the performance of the work for which this
i 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 INSP R s SIGNATU
Date opplicant ! COMPRESSOR BTU a s fJy n ROUGH f
NOTICE TO APPLICANT If after making this Certificate of VENTILATION SYSTEM FINAL
Exemption you should become subject to the Workers zx�_/ J.— :1!
Compensation provisions of the Labor Code you must forth EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked FURNACE FAURAVITY /��]
LICENSED CONTRACTORS DECLARATION FLOOR BTU U o
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 Code and my license is in full force and effect /t d
License Number 1 S 7 6 Z�o Lic Class C Z® , u
Otto a,r tr S« �P 5 Inr ae
Contrac r Date C%' O
❑ I am exempt under Sec W
Plan check fee IL
a
B 8P C for this reason PERMIT ISSUING FEE; () IS- Z
Date 21 2 9 8 A
Signature TOTAL FEE
OWNER BUILDER DECLARATION PLAN CHECK APPLICANT 2 !Z #t• • • • e
1 hereby affirm that I am exempt from the Contractor s License �J
Law for the following reason (Section 7031 5 Business and NAME 1 - 3225
Professions Code)
❑ I as owner of the property or my employees with ADDRESS • • • 32255
wages as their sole compensation will do the work and CITY NO
the structure is not intended or offered for sale(Section cl1 2 1 2—8 8
7044 Business and Professions Code)
L /
❑ I as owner of the property am exclusively contracting OWNER
with licensed contractors to construct the project (Sec MAIL
tion 7044 Business and Professions Code) ADDRESS
CONSTRUCTION LENDING AGENCY CI P p TEL NO yT
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 ) r sv tTe K G
ADDRESS r r
Lender s Name
Lender s Address CITY C.
ns TEL No
TATE LIC
I certify that I have read this application and state that the LICENSE NO l J — 6 .Z 0 CLASS I'— oZ O
above 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
upon the abov mentioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
/21- W_
SignaTi re of Applicant or Agent Date