HomeMy Public PortalAbout4920 ALESSANDRO AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 76A.364C 6 DPW 9/89 APPLICATION FOR PERMIT LIAVAIE GREEN
76A36
I hereby affirm that I have'a certificate of consent to self insure,
or._,,r w ficate 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.
EJ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING
ADDRESS
department. (PRINT OR TYPE ONLY) 1 T
Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALLY
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
ABSORPTION UNIT,BTU
(This section need not be completed if the work involved by the ASSESSOR C
MAP BOOK �.Si'Q PA E �� PARCEL�,3
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT No. PRocEss1 ev
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers' Compensation Laws.
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH - �
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION IFLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect.
License Number Lic.Class
Contractor Date ', �� O
❑ I am exempt under Sec. Plan Check fee 0
BAP.C.for this reason PERMIT ISSUING FEE$c;2—/ 30 0
Date: TOTAL FEE W
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT Z
I hereby affirm that I am exempt from the Contractor's License Law NAME r� iJ '
for the following reason (Section 7031.5, Business and Professions /� /` $
Code): ADDRESS ACCT o a
❑ I, as owner of the property, or my employees with wages 3303 35.70
as their sole compensation, will do the work and the CITY TEL.N _4
structure is not intended or offered for sale (Section 7044, t +�'�° m �1 ITEMSOC
Business and Professions Code). OWNER TOTAL
fl[lL�\I I, as owner of the property, am exclusively contracting MAIL KAY
with licensed contractors to construct the project (Sec- ADDRESS CHECK ;c�"j
tion 7044, Business and Professions Code). CHECKH
CONSTRUCTION LENDING AGENCY00
.
CITY /� TEL.NO _ CHANGE
I hereby affirm that there is a construction lending agency for CONTRA OR (/ , t1�3 VV
the performance of the work for which this permit Is issued
(Sec.3097, Civ.C.).
ADDRESS 0000_0001 4/ 9/96
Lender's Name pp y { I
CITY TEL.NO. 577(J Alµl 10:24
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
property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
`. ATURE F PLICAL R AGErJT DATE