HomeMy Public PortalAbout5033 SANTA ANITA AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
1'.hemby affirm that I have a certificate of consent to self
in*ute, or a certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy
""'L
ereof (Sec. 3800, C.) {A364
0046 9/88 r'
Policy Company+? Cs�� ° COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ CerTfied copy is hereby furnished.
❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. �` (PRINT OR TYPE ONLY) ADDRESS
Dat �+ 9"9 Applicar>! LOCALITY ��pL
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FR M 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.)
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM / �/ �A
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation
/Laws. BOILER, BTU APPROVALS DATE INSPECTOR'S SIGNATURE
Zti�44.0 Applica� �c�C/�4 COMPRESSOR, BTU. 3 G,d7-0 �� � ROUGH
NOTICE TO APPLICANT: If, after ma ing 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 GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
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.
' d
License Number Lic. Class , O
U
Contractor Date
❑ I am exempt under'Sec. O
Plan check fee u
W
B.AP.C. for this reason w
Date: PERMIT ISSUING FEE $ Z
Signature TOTAL FEE 3 Q
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
wages as their sole compensation,will do the work and ACCT.T
the structure is not intended or offered for sale(Section CITY TEL.NO.
7044, Business and Professions Code). OWNER773£t7 17.00
❑ I, as owner of the property; am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL 1 ITEMS
tion 7044, Business and Professions Code). ADDRESS/0
!/ .�
CONSTRUCTION LENDING AGENCY CITY TEL. NO. IL '� �—�
1 hereby affirm that there is a construction lending agency for CHECK 3-17.00
the performance of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.). h— , CHANGE .0D
D
ADDRESS '
Lender's Name
CI TEL. NO. 7 401 1 -� 1 -� n
Lender's Address 3-` � i tr 1 IG/ 3190
I certifythat I have read this application and state that the STATE LIC. y �j
PP LICENSE N 23 CLASS 31*8 1 AM1411:36
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 theabove-mentione property forinspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signatuf of Applicant or Agent Date