HomeMy Public PortalAbout5702 NOEL DR_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
qr a certif copy thereof(Sec 3 Lab C) 76A3
DPW 9/88 �
Policy N ompan
RCertified copy is hereby furnishA COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with th county building inspec FOR APPLICANT TO FILL IN BUILDING D
tIo7cleg7t (PRINT OR TYPE ONLY) ADDRESS
Date Applicant LOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTI FROM WORKER NEAREST
COMPENSATION INSURANCE CROSS ST
(This section need not be completed If the work involved by ABSORPTION UNIT BTU DISTRICT NO PROCESSED BY
the permit is for one hundred dollars($100)or less)
I certify that in the performance of the work for which this AIR HANDLING UNIT CFM
permit is issued I shall not employ any person in any manner
so as to become subject to the Workers Compensation Laws BOILER BTU j� APPROVALS DATE INSPECTOR S SIGNATURE
Date Applicant COMPRESSOR BT D v ROUGH
NOTICE TO APPLICANT If after making this Certificate of VENTILATION SYSTEM FINAL
Exemption you should become subject to the Workers IOU ME
Compensation provisions of the Labor Code you must forth EVAPORATIVE COOLER VALIDATION
with comp)ywith such provisions or this permit shall be deem
ed revoked FURNACE FAU Apt
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEA R SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business WALL I o
and Professions Code and my license is in full force and$ffect
License Num Lic Class Pool 40O
Contractor to + 7 OC
❑ I a xempt and c i V
Plan check fee V
B&P C for this reason Date PERMIT ISSUING FEE $ Z
Signature TOTAL FEE r
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 k
Professions Code) _
❑ i as owner of the property or my employees with ADDRESS
wages as their sole compensation will do the work and At. T,s
the structure is not Intended or offered for sale(Section CITY TEL NO
7044 Business and Professions Code) �aQ7 .tlt
OWNER _
F1 as owner of the property am exclusively contracting I ITEMS
with licensed contractors to construct the project (Sec MAILr
tion 7044 Business and Professions Code) ADDR S t_
i ITAL 5Ts. 00
CONSTRUCTION LENDING AGENCY CITY TEL N ��' tE��►ti stat all
hereby affirm that there Is a construction lending agency for
the performance of the work for which this permit is Issued CONTRACTOR , CHANGE O'l
(Sec 3097 Civ C)
Lender's Name ADDRESS
CI r1W0TEL NO
Lender s Address �_ � 1/10c
STATE LIC _ 49 I AM 1 i [I
I certify that I have read this application and state that the LICENSE NO CLASS(
T'.0 CLASSi z
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
upo h ov ntioned property for inspef ion purposes
t SEE REVERSE FOR EXPLANATORY LANGUAGE
SI re of Applicant 611gent Date es