HomeMy Public PortalAbout9509 PENTLAND ST_Mechanical__ WOIFKERS COMPENSATION DECLARATION f L
I hereby off min that I have a certificate of consent to self IAPPLICATION FOR PERMIT
insure aria certificate of Workers Compensation Insurance HEATING - VENTILATING - AIR CONDITIONING
org certified copy thereof (Sec 380D Lob C ) 76A364C -
CE 818(REV 10/81) -
-Pal icy No Company
' Certified copy is hereby furnished - - COUNTY OF LOS ANGELES .. BUILDING AND SAFETY
s
ID Certified copy is filed witl the county budding mspec- - FOR APPLICANT TO FILL IN BUILDING
tion department - (PRINT OR TYPE ONLY) ADDRESS 1 S►/ �� S
Date I Applicant LOCALI
y NO TYPE OF APPLIANCE OR EQUIPMENT _ FEE
CERTIFICATE OF EXEMPTION FROM'WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST
(This section need not be completed II the work Involred by ABSORPTION UNIT BN 711TRICTO P
the permit Is for one hundred dollars($100)or less ) ��` U
AIR HANDLING UNIT CFM
I certify that in the performance of the work for which this
permit is Issued I shall not employ any person in any manner BOILER BTU
so as to become subject to the Workers'Compensation Laws - APPuoVALS DATE IrvSPE[roR551GrvnruRE
ROUGH
Date Applicant _ /
NOTICE TO APPLICANT If, after making this Certificate of VC
MILATION SYSTEM - / FINAL
Exemption you should become-subject to the Workers
Compensation provisions of the Labor Code you must forth EVAPORATIVE COOLER VALIDATI
with comply with such provisions or this permit shall be ,
deemed revoked FURNACE FAU_GRAVITY
' I LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED—UNIT—
(commencing
USPENDED UNIT_(commencing with Section 7000)�of Division 3`of the Busmesi WALL
and Professions Code,and m license is In full force and effect _ IL
Y
License Number `/- 363 CcClass C'� , tJ
K
IC}o�ntr ari
actor of/Irv, 1"`/t�te`' //s7 O
VJ
I am exempt under Sec d
Plan check fee
B 8P C for this reason W
L9 Z
PERMIT ISSUING FEE j
Date �� I
Signature �I tJ .. _ TOTAL FEE fjD -
_ _ OWNER BUILDER RAN CHECK APPLIC T ,
I hereby affirm that I am exempt from the Contractor s License ,
Law for the following reason (Section 7031 5 Business and NAME T -
Professions Code) ,
❑ 1, as owner of the property or my employees with ADDRESS ' r
wages as their sole compensation wdl do the work and CITY ` TEL NO '
t the structure is not intended or offered for sale(Section '
7044 Business and Professions Code) q s r
_ T OWNER
❑ 1 as owner of the property am exclusively contracting MAIL
with licensed contractors to construct the project (Sec s'� ,
tion 7044 Business and Professions Code) ' ADDRESS I 12 6 O Q 7 A
CONSTRUCTION LENDING AGENCY CITY _ TEL NO
I hereby affirm that there is a construction lending agency for # e !, e } 8
the performance of the work for which this permit is issued CONTRACTOR
(Sec 3097 Cry C ) - s ,..y_ - 'i___a 51' • e.2 Q 5 O s
ADDRESS f
Lender s Name a e+e 2 Q JC 0-6"
CITYs TEL NO s �O / „ ._. -
Lender s Address 1 1,21 -86
STATIF LIC
I certify that I hove read this application and state that the LICENSE NO CLASS l 1'J .-- - - - - �.
above information is correct I agree to comply with all County ~
ordinances and State lows relating to building construction '
and hereby authorize representatives of this County to enter - -• - - '�'"'-- -
upon the bove mentioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of App cart or Agent Date
t -