HomeMy Public PortalAbout10932 WILDFLOWER RD_Mechanical__ WORKERS' COMPENSATION DECLARATION A P P�p C AT I O N FOR PERMIT
I hereby affirm that I have a certificate of consent to self
insu,Te, or a certificate of Wor4furni
mpensation Ins once, �I:��I�� ��AITILAHI�9G . AIR CONDITIONING
or d led copy ther o (Seb. 76A364C
Pol _�om 20-0046 DPW 9/88
❑ Certified copy is herebyd. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING O
ice-' 'ttgn department.
46 (PRINT OR TYPE ONLY) ADDRESS
Date,F ! T 7 Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTI N FROM WOR S' 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 \-`J ��
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 ,INS OR'S SIGNATURE
Date Applicant COMPRESSOR, BTU2 . 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 VUEID
with comply with such provisions or this permit shall be deem-
ed revoked.' FURNACE: FAU RAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU /
I hereby affirm that I am licensed under.provisions of Chapter 9SUSPENDED UNIT_
(commencing with-Section 7000)of Division 3 of the Business HEATER: WALL
and Professions Code,and my license is in full force and effect.
License Ni b S Lic. Class 2,D ® 0
O
V
Contractor Date � — I>C
E:1 - I exempt un Sec. U
B.&P.C. for this reason Plan check fee CL
Date: PERMIT ISSUING FEE $ Z
Signature TOTAL FEE
OWNER-BUILDER DECLARATIONPLAN 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): e
❑ ADDRESS
I, as owner of the property, or-my employees with
wages as their sole compensation,will do the work and r - ACCTA
the structure is not intended or offered for sale(Section CITY TEL.NO.
7044, Business and Professions Code). "" 3307 30.50
❑ -
I, as owner of the property, am exclusively contracting OWNER MAIL \ 1 ITEMS
with licensed contractors to construct the project (Sec- 7
tion 7044,'Business and Professions Code). ADDRESS d J TOTAL 310m50
CONSTRUCTION LENDING AGENCY CITY TEL. N .�� �olo�r.. CHECK 30.50
I hereby affirm that there is a construction lending agency for r,
the performance of the work for which this permit is issued CONTRACTOR 9` / ® CHANGE .00
(Sec. 3097, Civ. C.).
ADDRESS /
Lender's NameCIT TEL. NO. / 130030_01301 '82/16/89
�o - C�/
Lender's Address LIC. 5120 1 AI111-04
I certify that I have read this application avid state that the LIT EATE NSE NO.-7,-),— �-- CLASS Z/
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
an ereby orize representatives of this County to enter
on - entioned pr perty for inspection purposes.
4 e — SEE REVERSE FOR EXPLANATORY LANGUAGE
,/Xn'o'tJre of Applic or Agent Date