HomeMy Public PortalAbout5136 AGNES AVE_Mechanical_10/28/1991_ WORKER'S COMPENSATION DECLARATION 46DPW 9/89 APPLICATION FOR PERMIT LI E GREEN,
I hereby affirm that•- 76A3I have a certificate of consent to self insure, 76A364C
or a certificate of Worker's Compensation Insurance, or a certified HEATING -VENTILATING -AIR CONDITIONING
copy thereof(Sec.3800 Lab. C.)
Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑
Certified copy is hereby furnished. BUILDING
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❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN ADDRESS
department. (PRINT OR TYPE ONLY)
LOCALITY
Date Applicant
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. r'`' L.C*ir{Q
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
This section need not becompleted b leted if the work involved ASSESSOR
( P Y the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify.that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to I BOILER,BTU
become subject to the Workers'Compensation Laws. _ d
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Date A licant APPROVALS DATE INSPECTOR'S SIGNATURE
PP VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. , J FURNACE: FAU RAVIyY
LICENSED CONTRACTORS DECLARATION / FLOOR BTU / J d VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATERSUSPENDED UNIT
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(commencing(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code,and mylicenseis in full force and effect.
License Number �/ I Lic.Class
Contractor " Date I O —21— ` Poo. 0
❑ I am exempt under Sec. -Plan Check fee
B.&P.C.for this reason PERMIT ISSUING FEE$ O
Date: TOTAL FEE W
Signature �EU �r, __ W
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License Law NAME Nov
for the following reason (Section 7031.5, Business and Professions '" "' '
Code):
ADDRESS
F] �2,� � �Z�✓�"t �t�.t,-_
I, as owner of the property, or my employees with wages ^
as their sole compensation, will do the work and the CITY �U I K TEL.NO.LJbb
structure is not intended or offered for sale (Section 7044, UI
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Business and Professions Code). OWNER j�1C� -0 t 0 "
❑ I, as owner of the property, am exclusively contracting MAIL Y I;[� /��� �Q( t' t"•U+ .1-U-1
with licensed contractors to construct the project (Sec- ADDRESS 5 ✓ Took /
tion 7044, Business and Professions Code). �q
CONSTRUCTION LENDING AGENCY CITYT t t 1 G TEL.NO. '7`1n
Iherpeby affirm that there is a construction lending agency for CONTRACTOR
the erformance Of the work for which this permit Is issued
(Sec.3097,Civ.C.). p _
- - ADDRESS -
Lender's Name � � !�V
CITY �J V I(� TEL.NO. 1 U0
Lender's Address STATE / LIC. Q� - - -
I certify that I have read this application and state that the above LICENSE NO.�j �7 I CLASS r/
information is correct/f agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
represe tives of t ounty to enter upon the above-mentioned
prop for in a tion rposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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SIGNATURE OFA PLICANT R
IT DATE