HomeMy Public PortalAbout9821 WINDSOR LN_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby gffirm 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
Policy No.1047159 Company STAT:'] FUND 20-0046 DPW 9/88
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
s Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. ADDRESS 9821 WINDSOR LANE
(PRINT OR TYPE ONLY)
Dat —29-90 Applicant R. R014AND LOCALITY r1'.1.2LE CITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST LOidER AZUSA RD.
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 �O
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
Date Applicant 1' COMPRESSOR, BTU 60,000 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 VALIDATION
with comply with such provisions or this permit shall be deem-
ed revoked. 1 FURNACE: FAU X GRAVITY .i
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.
519622 C-20 �a �2 CL
O
License Number Lic. Class ,
ContractorR&R' HTG&AIR Date 10-31-91 U
99
❑ I am exempt under Sec. V
Plan check fee
LU
B.&P.C. for this reason CL
Date: PERMIT ISSUING FEE $ Z
Signature TOTAL FEE
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 ACC
—11
wages as their sole compensation,will do the work and CITY TELNO. +=37 E-' ' t�
the structure is not intended or offered for sale(Section I r JI.0:
7044, Business and Professions Code). I =�;,-:
❑ I, as owner of the property, am exclusively contracting I OWNER j;,jESTCO LAND CO. IUCF
with licensed contractors to construct the project (Sec- MAIL TOTAL
tion 7044, Business and Professions Code). ADDRESS 9fe . 57 .00
CONSTRUCTION LENDING AGENCY CITY F, CHECK _,7.00
T.�d+�1P1� CITY TEL. NO. 286-3636
I hereby affirm that there is a construction lending agency for CONTRACTOR R&F HTG & AIR C OND. , CHANGE .1113
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
ADDRESS 1504—B INDUSTRIAL PARK
Lender's Name tiJ 1llLF 113111:-31 101123/90
CITY C OVTNA TEL. NO. 966-0011
Lender's Address Ltt_�i a j ;{`�it� 3'
1 certify that I have read this application and state that the LICENSE NO. 519TATE622 LIC.
ASS C-20
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 the ab ve-mentioned propert nfor inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
ignatur
ee of Applicant or Agent Date
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