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HomeMy Public PortalAbout9005 PENTLAND ST_Mechanical__ , ' WORKERS COMPENSATION DECLARATION •r ffmm•th.1 1 have o certificgtetbf consent to self I APPLICATION FOR PERMIT re `b,cerhflcole of Workers Compensation Insurance 7aAae4C , - HEATING - VENTILATING ,- AIR CONDITIONING a certified copy thereof (Sec 3800 Lab C ) P . CE 818(REV 10/81) - •- - - Poltcy No Company❑ Certified copy whereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY' Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUDDING Pjffv tion department c (PRINT OR TYPE ONLY) ' ADDRESS O©S _ Date Apphcont . , LOCALITY /J ` NO TYPE OF APPLIANCE OR EQUIPMENT, FEE l.• CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST COMPENSATION INSURANCE CROSS ST ^ (This section need not be completed R the work Involved by J ABSORPTION UNIT BTU DlsiRlCi NO PROCE V the permit Is for one hundred dollars ($100) or less ) AIR HANDLING UNIT CFM I certify that to the performance of the work for which this permit is Issued I shall not employ any person to any manner BOILER BTU so as to become subject to the Workers mpensation aws uu - APPROVALS DATE INSPECTOR S SIGNATURE (j ,� V"70� �' Dote 7 —/?-�.Tappbcan 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 VALIDAT N with comply with such provisions or this permit shall be deemed revoked " FURNACE FAU G A ITY" LICENSED CONTRACTORS DECLARATION FLOOR BTU I hereby affirm that lam licensed under provisions of Chapter 9SUSP ' SUSPENDED—UNIT— WALL (commenting with Section 7000) of Division 3 oHEATER ENDED UNIT_ f the Business_ ' and Professions Code and my license is in full force and effect ��Y93 S'S G� 2 0 License Number Lt< Class - , U Ooatractorfiby Date r - 0 Ir�[yf 1 am exempt under Sec ry Plan check fee 1 H B&P C for thrs reason are r Z �y_ PERMIT ISSUING FEE $ 0 ' Signature TOTAA FEE 42) 0 iOWNER-BUILDER DECLARATION PLAN CHECK APPLICANT c k I here6y'affir'm that I a`m e`xempt from the Contractor s License_` Law for the following reason (Section 7031 5 Business and NAME '�-; ��• =y- , a - - z� _� _ v - Professions Code) El1,I, as owner of the property or my employees with �D p (�.Mc � • wages as their sole compensation will do the work and - r ' the structure is not Intended or offered for sale(Section CITY TEL NO 33103/4 - 7044 Business and Professions Code) - t OWNER I' I os owner of the property am exclusively contracting with licensed contractors to construct the project (Sec MAIL 49 n O ' hon 7044 Business and Professions Code) ADDRESS J r CONSTRUCTION LENDING AGENCY CITY - TEL NO �0 6 7 0 A I hereby affirm that there is a construction lending agency for ��If 9 V # 0'0!0 • e 8 the performance of the work for which this permit Is Issued (Sec 3097 Gv C ) CONTRACTOR A S s 9t.4 le _ - I a, _( is 111 Q 5 0 �Q • e Lender s Name ADDRESS / .. - _ _ . . �` � r� Q 5 0 5 + CITY ` TEL No p �_(p • �0 9 A 4'-8 8 Lender s Address -- - STAT Allf �a ? LIC /7 I certify that I have read this application and state that the -s LICENSE NO p- - CLASS 0' _ _ 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 the ve on r p rty for nspection purposes SEE REVERSE FOR EXPLANATORY-LANGUAGE C ,�i41-9pR Signature of Applicant or Agent Date '- '- .• + - - ._- -