HomeMy Public PortalAbout10249 NADINE ST_Mechanical__ WORKERS COMPENSATION DECLARATION
hereby affirm that I have a certificate of consent to self APPLICATION FOR PERMIT
Insure or o certificate of Workers Compensation Insurance
or a certified copy thereof (Sec 3800 Lab C) 76A364C HEATING - VENTILATING AIR CONDITIONING
20 0046 DPW 9/88
y�o'M'' Company
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
tion department (PRINT OR TYPE ONLY) ADDRESS 0 Z
Date Applicant I
OCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
71—
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST /
COMPENSATION INSURANCE CROSS ST 10C /7
(This section need not be completed If the work Involved by ABSORPTION UNIT BTU DISTRICT NOPROCESS 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 v
permit is Issued I shall not employ any person in any manner BOILER BTU
so as to become subject to the Workers Compensation Laws x APPROVALS DATJ 41FINSPECTOR S SIGNATU
Date 12-/f' rar Applicant.G�W / ` COMPRESSOR BTU y OHO ROUGH
17
NOTICE TO APPLICANT If after making th Certi tate of VENTILATION SYSTEM FINAL
Exemption you should become subject to the Workers 4i�
Compensation provisions of the Labor Code you must forth EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be deem
ed revoked FLOONRCE FAU BTU 7
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 WALL
and Professions Code and my license Is in full force and effect U— T-5
y �iy9 }
License Number � Llc Class , �
/ 2 , �� tis 5
Contractor Date /A '?a ZO U
❑ I am exempt under Sec 0
Plan check fee u
B 8P C for this reason Date PERMIT ISSUING FEE $ O Z
TOTAL OTAL FEE
OWNER BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor s License ,
Law for the following reason (Section 7031 5 Business and NAME
Professions Code) D
❑ I as owner of the property or my employees with ADDRESS
wages as their sole compensation will do the work and ALLT.v
the structure is not intended or offered for sale(Section CITY TEL NO Jv�7
7044 Business and Professions Code) 1
❑ OWNER V 1 ITEMS
46 25
I as owner of the property am exclusively contracting
with licensed contractors to construct the project (Sec MAIL /� TOTAL
tion 7044 Business and Professions Code) ADDRESS U O V r
CONSTRUCTION LENDING AGENCY CITY TEL.NO CHECK 46.25
1 hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTOR '� �� f f` Poo
.00
(Sec 3097 Civ C)
ADDRESS
Lender's Name �����y�
rr i 0000'—M i IV 11/89
Lender s Address CITY
I� RC dr � / d �� NO y � �' �4d7 1 AM 98-C
1 certify that I have read this application and state that the LICENSE NO CLASS /�
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 ab ov mentioned property for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
ignature of Applic or Age Dote�—
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