HomeMy Public PortalAbout4821 ALESSANDRO AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION DPW
76A364APPLICATION FOR PERMIT �' GEREEN
76A364C
I hereby affirm that I have a certificate of consent to self insure,
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. /I p
BUILDING �/�02� L�crrPi4
Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN ADDRESS 7
department. (PRINT OR TYPE ONLY)
Date Applicant LOCALITY
PP NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST L_0`1/e,r f'/'�
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COMPENSATION INSURANCE CROSS
ABSORPTION UNIT,BTU ASSESSOR
ST.
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(This section need not be completed if the work involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU ��
become subject to the Workers'Compensation Laws. ytyy�cy
COMPRESSOR,BTU
Date A pllcant APPROVALS D TE INSPECTOR'S SIGNATURE
P VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH Z
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL 2
provisions or this permit shall be deemed revoked. FURNACE: FAU - GRAVITY VALIDATION
LICENSED CONTRACTORS DECLARATION FLOOR BTU
hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect.
License Number Lic.Class
Contractor Date V
F1 Plan check fee
I am exempt under Sec.
A,i•;=-
B.&P.C.for this reason PERMIT ISSUING FEE$ F•-
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Date: TOTAL FEE d
Signature J. I i-=11 (�
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License Law NAME
for the following reason (Section 7031.5, Business and Professions LA,_gS2i ( C,-;,L
Code): ADDRESS
ElI, as owner of the property, or my employees with wages ✓Z. e-$S rG
as their sole compensation, will do the work and the CITY., C TEL.NO. 2__g'J (_[
— 1 Q
structure is not intended or offered for sale (Section 7044, TT II
Business and Professions Code). OWNER5•S
I, as owner of the property, am exclusively contracting MAIL ins"°t
with licensed contractors to construct the project (Sec- ADDRESS ,�S S an
Y"
tion 7044, Business and Professions Code). i (/
CONSTRUCTION LENDING AGENCY CITY IR * TEL.NO.
I hereby affirm that there is a construction lending agency for CONTRACTOR o ,
the performance of the work for which is permit Is issuad
(Sec.3097,Civ.C/)?. r i
ADDRESS
Lender's Name
CITY TEL.NO. '
Lender's Address STATE LIC.
I certify that I have read this application an state that the above LICENSE NO. CLASS
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 above-mentioned
do
rty for inspection '10pses. _ _ SEE REVERSE FOR EXPLANATORY LANGUAGE
IG E OF APPLICANT OR A NT DJITE