HomeMy Public PortalAbout9508 PENTLAND ST_Mechanical__ WORKERS CI have COMPENSATIONDECLARATION
of corse APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self
insure 9r o certificate of Workers' Compensation Insurance - A HEATING•- VENTILATING - AIR CONDITIONING
76A364f
or a certified copy thereof (Sec 3800 Lab`C )
CE 810(REV 10/81) '
Policy No Company
Certified copy is hereby furnished COUNTY OF LOS ANGELES - BUILDING AND SAFETY
_ �
❑ Certified copy is filed with the county budding inspec- FOR APPLICANT TO FILL IN BUILDING
hon department P (PRINT OR TYPE ONLY) ADDRESS 2
l
Date Applicant LOCAU
NO TYPE OF APPLIANCE OR EQUIPMENT . FEE
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST
i, "
. `fz I
COMPENSATION INSURANCE I': CROSS ST C/ c�(i
(This stolon need not bo completed If the work Involved by ABSORPTION UNIT BTU DISTRICT NO PROCESSED BY
the permit Is for one hundred dollars ($100)or leu ) it �� O
AIR HANDLING UNIT CFM V ( (X,
I certify that in the performance of the work for which this _
permit Is issued, I shall not employ any person in any manner
so as 10 become subject to the Workers.„omapeensasat'tion ws f� BOILER BTU AIPp VALS DATE CTOR S SIGN RIE
it�
Apav
X Date 4-S- aAppl i cant COMPRESSOR BTU UN ROUGH
NOTICE TO APPLICANT If after making this Certi iaate of VENTILATION SYSTEM U� FINAL
t Exemption, you should become subject to the Workers, _
Compensation provisions of the Labor Code you'muit forth-' EVAPORATIVE COOLER L ATION
with comply with such provisions or this permit shall be
deemed revoked 4 FURNACE FAU_GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby off irm that I am licensed under provisions of Chapter 9 HEALER SUSPENDED-UNIT—
(commencing
USPENDEDUNIT_(commencing with Section N000) of Division 3 of the Business WALL
and Professions Code and my license is in full force and effect
U o
License Number Uc Class * - - , V
K
Contractor Date - OO
❑ I am exempt under Sec suit
Plan-check fee a.
B 8P C for this reason PERMIT ISSUING FEE $
Date
Signature
TOTAL FEE ;R9 3 511 A
, _ t
OWNER BUILDER DECLARATION - PLAN CHECK APPLICANT # e ie • is e 8
I hereby affirm that I am exempt from the Contractor s License , ( - 7 7 a 5 O
Law f r the following reason (Section 7031 5 Business and NAME x
Pro ions Code)
I as owner of the property, or my employees with ADDRESS e,e • 7 5 (]5P
wages as their sole compensation will do the work and CITY R TEL NO v Q, 08-88
the structure Is not Intended or offered for sole(Sedan 0
7044 Business and Professions Code) I -
❑ OWNER ( U(OA
I as owner of the property am exclusively contracting �-£—
with licensed contractors to construct the project (Sec- MAILDRESS
tion 7044 Business and Professions Code) ' ADr GN
CONSTRUCTION LENDING AGENCY CITY 'rPLC GI • TEL NO ZVb< U
I hereby affirm that there is a construction lending agency for "T '
the performance of the work for which this permit is•issued CONTRACTOR s `
(Sec 3097 Civ C )
ADDRESS 4
Lender s Name +�
CITY _ TEL NO _
Lender is Address
STATE LIC
I 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
a dl antes and State jaws relating to building construction
a h relay and.,
a represenot of this County to enter "
up t e ob e- s ttlp. d property for in ech n purposes _ - l _ Y T
`/ _ SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of AppLcant or Age Date 7 '