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HomeMy Public PortalAbout6334 TRELAWNEY AVE_Mechanical__ WORKERS COMPENSATION DECLARATION APPLICATION FOR PERMIT y1 herek offr that I have a certificate of consent to self im'u?e or a certificate of Workers Compensation Insurance 0 3 nifI cop thereof (Sec 3800 ob C ) \/ 76A364C HEATING • VENTILATING - AIR CONDITIONING / z / CE 818(REV I0,81) `pall ompany L enified copy IS hereby furnishe COUNTY OF LOS ANGELES BUILDING AND SAFETY ❑ Cenified copy is filed with the county building iFOR APPLICANT TO FILL IN BUILDING -/} on department \ (PRINT OR TYPE ONLY) ADDRESS .7c/ " R,e/4�NC WA /-/ � APNO TYPE OF APPLIANCE OR EQUIPMENT FEE Plcant 1( TY / /•, CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST COMPENSATION INSURANCE CROSS ST (This section need not be completed If the work Involved by ABSORPTION UNIT BTU 75, or RtOCESSED BY the permit is for one hundred dollars ($100)or Ion) AIR HANDLING UNIT CFM I certify that in the performance of the work for which this permit is Issued I shall not employ any person in any manner so as to become subject to the Workers Compensation Laws BOILER BTU Al VATS DATE SKFoR S SIGN URE Date Applicant I COMPRESSOR BTU �(,/ ROUGH 0i 4&40`ajj Af of NOTICE TO APPLICANT If after making this Certificate of VENTILATION SYSTEM FINAL Exemption you should become subject to the Workers Compensation provisions of the Labor Code you must forth- EVAPORATIVE COOLER VALIDATJW with comply with such provisions or this permit shall be deemed revoked FURNACE FAU_G LICENSED CONTRACTORS DECLARATION I FLOOR —BTii U-= hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED—UNIT— (commencing USPENDED UNIT_(commencing with Section 70DO) of Division 3 of the Business WALL and Professions Code and my license is in fullfqrce and effect ❑ SSO License NumberX03735 Lm ClassSry V Contractor CMA/DR aP��1����rQ K0 I am exempt under Sec Y W Plan check fee h B 8P C for this reason !' 0 1 i�. 1 A Dore Z PERMIT ISSUING FEE$ V # e e e e e g Signature � OWNER BUILDER DECLARATION RAN CHECK APPLICANT FEE ICAN7 .1 --- 3Q50 I hereby affirm that I am exempt from the Contractor s License , a -,- 3(1505 Law for the following reason (Section 7031 5 Business and NAME Professions Cade) ❑ 1 as owner of the property, or my employees with ADDRESS O,Q 7 8 8 8 wages as their sole compensation will do the work and the structure Is not intended or offered for sole(Section CITY TEL NO 7044 Business and Professions Code) n OWNER qA ❑ I, as owner of the property am exclusively contracting with licensed contractors to construct the project (Sec MAIL -y3 ,e � (,c/Np tion 7044 Business and Professions Code) ADDRESS 3 CONSTRUCTION LENDING AGENCY CITY 7LtO / ( i TEL NO /— I hereby affirm that there is a construction lending agency for 6 J the performance of the work for which this permit is issued CONTRACTORQ �� C v pool 3097 Civ C ) ADDRESS / N �i /.irJ� � •, Lenders Name / /3/Jr CITY TEL NO b�t , Lender sAddress /}TATE // I certify That I have read this application and state that the LICENSE NO (/3735 CLASS CaO above Information is correct 1 agree to comply with all Count' ordinances and Statejaws relating to building construction, and hereby authorize representatives of this County to enter upon abov mentioned p for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE a. W Signature of Appbcaer or AReni Date