HomeMy Public PortalAbout4908 ALESSANDRO AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89 APPLICATION FOR PERMIT Lim" E GREEN
hereby affirm that I 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(Seb.3800 Lab.C.)
Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
F-1, Certified copy is hereby furnished.
❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING� /,g �b�
PRINT OR TYPE ONLY) ADDRESS d 1 t I�Ss
department. (
Date Applicant LOCALITY—,-&d4 T C tCA
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST w
CROSS
COMPENSATION INSURANCE
ABSORPTION UNIT,BTU ASSESSOR
(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. BA �OOv 9 �po Q
COMPRESSOR,BTU -
APPROVALS DATE INSPECTOR'S SIGNATURE l
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making'this Certificate ofROUGH �z-
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,.you must forthwith comply with such FINAL —S
provisions or this permit shall be deemed revoked. 11PA FURNACE: FAU G AV TY
LICENSED CONTRACTORS DECLARATION FLOOR BTU UO VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED—UNIT—
(commencing
USPENDED UNIT(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code, and my license is in full force and effect.
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License Number Lic.Class,
Poo.
4 _ CL
0
Contractor Date . . .,. ......................... .. _... U
❑ Plan check fee .. .......
}__ i; :c 1=�Y
I am exempt under Sec. _L e _r O
B.&P.C.for this reason PERMIT ISSUING FEE 4/-,1
Date: TOTAL FEE 1 iL 14 - 45 1GW.
Signature IIL
PLAN CHECK APPLICANT' CHECK3' , C
OWNER-BUILDER.DECLARATION t t It o•!C Z
I hereby affirm that I am exempt from the Contractor's License Law NAME , CHANGE
for the following reason (Section 7031.5, Business and Professions
Code): ADDRESS
I, as owner of the property, or my employees with wages 0000-00111 6/14/93
as their sole compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale (Section 7044, 13238 i Ail 23-:14
Business and Professions Code). J OWNER
r-1 DDn G-
1, as owner of the property, am exclusively contracting' MAIL
with licensed contractors to construct the project (Sec- ADDRESS 4Q40fs
tion 7044, Business and Professions Code). Q�
CITY TEL.NO.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for NTRACTOR
the performance of the work for which this permit Is issued
(Sec.3097,Civ. C.).
ADDRESS
Lender's Name
CITY TEL.NO.
Lender's Address STATE LIC.
I certify that I have read this application and 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
/pprroperrttyy for
°inspection
purposes. -/!_ f SEE REVERSE FOR EXPLANATORY LANGUAGE
� SIG�IP TURF OF APPLICANT OR, UN I (r�' 'W/1