HomeMy Public PortalAbout5424 ROBINHOOD AVE_Mechanical__ WGRKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT
01ieril2Y or affirm that I have a certlficate of consent to,self
Inslre, p cerHflcate of Workeri Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a TpA`Vfie ,copy th eof (Sec. 3800, Lob. C.) 7&4� 9/88� {o
Policy N —Company A ctl'11
Certified copy Is hereby'furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy Is filed with the county,bullding Inspec- FOR APPLICANT TO FILL IN BUILDING
'tion department. (PRINT OR TYPE ONLY)
, LOCALITYDate I O Ilc TYPE OF APPLIANCE OR K4UIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCECROSSST.
(This section read not be co mr
completed If the work IoNed by ABSORPTFON UNIT,BTU pSTRICT NO. PROCIMSM BY
the parmlt Is for one hundred dollars ($100) or lass.)
I certify that In the performance of the work for which this AIR HANDLING UNIT, CFM
permit Is Issued, I shall not employ artyn In arty manner
so as to become subleci to the Workers Compensation Laws. BOILER, BTU APPROVALS DATE INsPLL76R's s7o4ATuw
COMPRESSOR, BTU ��� �' ROUGH
Date ArpllcCOMPRESSOR, �
.NOTICE TO APPLICANT: If, after making this Certificate of Ve7MLATI0N SYSTEM FINAL
Exemption, you should become sublect to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE.COOLER VALIDATION
with comply with such provisions or this permit ihall be deem-
ed revoked. FLI R�RNR/10E: FAU Vm ;
LICENSED CONTRACTORS DECLARATION BTU 42
I hereby affirm that I am Ilcwisad under provisions of Chapter 9 HEATED SUSPENDEDUNIT
(commencing with Section 7000)of Division 3 of the Business WALL
and Professions Code,and my license Is In full force and effect. a
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License Number � I Ic. Class� , O
Contractor s"i ^' �'`�! Date l /7 IX
ElI am exemptO
- I under Sec.
Plan check fee G
B.BP.C, for this reason —Data
PERMIT ISSUING FEES
e. TOTAL FEE II
Signal . 1
ER-BUILDER DECLARATION PLAN CHECK APRJC NT �, l�-r CJa�'afi• j
I hereby affirm that I am exempt from the Contractors License
Low for the following reason (Sectlon 7031.5, Business and NAME-
Professions Code):
❑ I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and ACCT.
nTEL T
the structure Is not Intended or offered for sale(Section CITY I2. Ga.. NO.—) '� — 1- �-+�
70", Business and Professions Code). OWNER . 33017 E
NE7-0.)
❑ I, as owner of the property, am exclusively contracting 1 1TE%
with licensed contractors to construct the project (Sec-
tion 7044, Business and Professions Code). ADDRESS TOTAL 57 �.Q0
CONSTRUCTION LENDING AGBJCY CITY —C, C_ TELNO.
I hereby afflrm that there Is a construction lending agency for , t C}: 57.W
the performance of the work for which this permit Is Issued CONTRACTOR
(Sec. 3097, Civ. C.). C}{ (� .00
ADDRESS 3-2,
t 8
Lenders Name
Lender's Address CITY TEL. NO. "7 1`017—7 U 0000-0001 10/18/90
STATE UG AM*364 1 7:;t2
I certify that I have read this application and state that the LICENSE NO. � y CLASS .A7v't I7t
above Information Is correct. I agree to comply with all County
ordinances and State laws relating to bullding construction,
and hereby authorize representatives of this County to enter
upon the above-mention property for Ins pu
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� SEE REVERSE f-0R EXPLANATORY LANGUAGE
gent Date tDt