HomeMy Public PortalAbout5031 SANTA ANITA AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION A P P��CAT I®N F®R `I�E RM I T
`I;hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance, HEATING . VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec. 3800 Lab. C.) ,76A364C.�
y 4 lo.� D 00.!=gipiri 0046 13Pw 9iee
Folic "Jo. man LGe'
❑ Cehified 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
tion department. ADDRESS
n (PRINT OR TYPE ONLY)
Date4z' Applicant 2 LOCALITY
.1 11 IL NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
'CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
(This section need not be completed if the work Involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED 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 �,f'�
permit is issued, I shall not employ any person in any manner
so as to become subject to the kers'CO BOILER, BTU
en5a}IOn Laws. ` APPROVALS DATE INSPECTOR'S SIGNATURE
Dated Applicant COMPRESSOR, BTU � ��� / ROUGH
NOTICE TO APPLICANT: If, after m king this Certificate of VENTILATION SYSTEM FINAL "/- 5. D -V_
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. 1 FLOOR CE. FAU GRAVITY �^
LICENSED CONTRACTORS DECLARATION BTU ff-
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business WALL.
and Professions Code,and my license is in full force and effect.
IL
License Number Lic. Class O
u
Contractor Date
❑ I am exempt under Sec. _ 0
Plan check fee u
w
B.&P.C. for this reason PERMIT ISSUING FEE $
Date:
TOTAL FEE
Signature ;
OWNE -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): ADDRESS s;
F-1 1, as owner of the property, or my employees with
•
wages as their sole compensation,will do the work and �{• g
CIN TEL. NO.
the structure is not intended or offered for sale(Section OWNER _
7044, Business and Professions Code). 3,�0 37.00
'❑ _ _I, as owner of the property, am exclusively contracting i T C
with licensed contractors to construct the project (Sec- MAIL i i L•1 '`
tion 7044, Business and Professions Code). ADDRESS T 1 TALI 37 .00
CONSTRUCTION LENDING AGENCY �1/
I hereby affirm that there is a construction lending agency for CITY TEL. NO. �C7 i;HECK 37azI{,
the performance of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.). �� ® HAN GE
ADDRESS ,O-
Lender's Name :P1
Lender's Address CITY r/ LIC TEL. NO f�r 7 ;I,j�,i;1-[I0o i 10/SATE
1 certify that I have read this application and state that the LICENSE NO. /�� CLASS 318
ANi e•'-.�
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 th ove-menti ned property for inspection urposes.
�' SEE REVERSE FOR EXPLANATORY LANGUAGE
Sign ure of Applicant or Agent Date