HomeMy Public PortalAbout9933 NADINE ST_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to,self '
insure, or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
OF a certifi$d,copy the//reof (Sec. 3800, Lab. C.) 76AW4C r
PooNcy No Sw Company Q��InCJN 200046 DPW 9/.88 :.
-EJCertified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
I�'�'[�I Certified copy is filed with the county building inspec FOR APPLICANT TO FILL IN BUILDING
T'^ tion department. I ADDRESS "J 3 3 IVA-A w
//,. (PRINT OR TYPE ONLY)
Date g Applicant V rC+� Cs uS 'V�. LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT - - FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
•COMPENSATION INSURANCE CROSS ST.
(This section need not be.completed If the work Involved by ABSORPTION UNIT, BTU' DISTRICT NO. PR SSED BY
the permit Is for one hundred dollars ($100) or less.) /� J�(�
I certify th' i n'"' the performance of the work for which this AIR HANDLING UNIT, CFM J o
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 INSPECTOR'S SIGNATURE
' COMPRESSOR,'BTU 0 O ROUGH
Date Applicant
NOTICE TOAPPLICA"NT:' If, after making this Certificate,ofVENTILATION SYSTEM FINAL
-
Ezemption;_ you' should'become subject to the Workers'
Compensation provisions'of the.Labor Code, you must forth-
EVAPORATIVE COOLER LI ATI
with comp) with such provisions or this permit shall be deem-
" ed revoke FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I Hereby affirm that I am licensed under provisions of Chapter 9SUSPENDED 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.
/'�f/ u
License Number 7'/C� / Z Lic. Class , d
/ / ��►„ s 5
Contractor/�myr5 Iow3FG Date
OC
❑ I am exempt under Sec. .
Plan check fee U
B'BP.C. for.this reason ----Date: LU
PERMIT ISSUING FEE $ Z
Signature TOTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 006
I.hereby.affirm-that.I am exemptfrom the Contractor's License
Law for the following reason (Section 7031.5, Business and NAMEO S' .643ri + V�x1i� ►.
Professions Code): p �O'l . ,O l
❑ I, as owner of the property, or my employees with ADDRESS- 0 F.v Jw a A .
wages as their sole compensation,will do the work and n 1 IT18
the structure is not intended or offered for sale(Section CIN `'lett OfZ Al TEL. NO. / 3 ..
7044, Business and Professions Code). TOTAL 38 v 01)
�.t
ElI,,as ownOWNER er of the property, am exclusively contracting' �KAIC d# l�+��Sh.- CHECK ®0
with licensed contractors to construct the project (Sec- MAIL p
tion 7044, Business and Professions Code). ADDRESS . .4 3 lb iovCHANGE .00
CONSTRUCTIONLENDING AGENCY CITY TC { TEL. NO.28')_
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTOR O
(Sec. 3097, Civ.-C.). U 5 0 5}� eh �01 lw��iv�..�iq
Lender's.Name ADDRESS 0 v ws4� r4 , 7592 1 AM v:i•J
CITY (Fw OtC TEL�N9. /#� 366
Lender's Address
STATE
I certify that I have read this application and state that theLIC
uCENSE,NO. —7 y�O�t 2 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
u on the above-mentioned property for inspection'purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE.
S' ature of Applicant or Agent / Date