HomeMy Public PortalAbout5416 PERSIMMON AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION /, C° k; Z. M. 6 9AWLOOrCATION FOR PERMIT
I hereby Fffirm that I have a certificate of consent to self
Einsure,or.,p certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or,a certified copy thyrof (Sec. 3800, Lab. C.) 76A36aC
LAJ(o I•fit J_y Z !7 20-0046 DPW 9/88
lfcy No. Company �u oFL" r Q 9— INck-'�t a'.� c%
Irl Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING - -j
C-4n ( S e rvh
tion department. ADDRESS
L F (PRINT OR TYPE ONLY)
Date /— /v 90 Applicant D t1�L1 n, � " ,n I&C LOCALITY -
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
ABSORPTION UNIT, BTU DISTRICT NO PROCESSED
(This section need not be completed if the work Involved by
the permit is for one hundred dollars($100)or less.)
AIR HANDLING UNIT, CFM
I certify that in the performance of the work for which this I
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. B BOILER, BTU APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant 6 COMPRESSOR, BTU ®0 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 VALIDATION
with comply with such provisions or this permit shall be deem-
ed revoked. FURNACE FAU ,d G ITY10
LICENSED CONTRACTORS DECLARATION
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 Business WALL
and Professions Code,and my license is in full force and effect.
_ p is C'
License Number �� 7' 6 Lic. Class VIP // d
4' a�uc %ok's (i1C Zcvw �aY A('`� u
Contraltor Date 6,-3 c' ' Im
❑ I am exempt under Sec. U
Plan check fee ue
B.&P.C. for this reason PERMIT ISSUING FEE $ d
H
Date:
Z
TOTAL FEE
Signature
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
Professions Code):
❑ I, as owner of the property, or my employees with ADDRESS A v-I u V
wages as their sole compensation,will do the work and CITY TEL. NO.
the structure is not intended or offered for sale(Section . 307 44.511
7044, Business and Professions Code). OWNER
❑ I, as owner of the property, am exclusively contracting MAIL
t i ITEMS
with licensed contractors to construct the project (Sec- ADDRESS ✓ ° M TOTAL 4-4.5I=
tion 7044, Business and Professions Code). 0
CONSTRUCTION LENDING AGENCY CITY- - L • TEL. NO. e (: {:Y, 44 0'''1]
1 hereby affirm that there is a construction lending agency for - �r
the performance of the work for which this permit is issued CONTRACTOR % J ci ` ® CHANGE .00
(Sec. 3097, Civ. C.).
Lender's Name ADDRESS j-iy e �O. t' 4 i • r� i fG
CIN �� CA TEL. NO. g-o 1}�1�U'�01�1 10/1-51f 4'q
Lender's Address _ d r L
I certifythat I have read this application and state that the STATE LIC. 647s 1 Ati �
pp LICENSE NO. ' �— � 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
upon the above- entioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
/ �_ :3-
Signature of Applicant or Agent Dat