HomeMy Public PortalAbout5037 ALESSANDRO AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 2646 DPW 9,69 APPLICATION FOR PERMIT LIME GREEN
I hereby affirm that I have a certificate of consent to self insure, 76A3A364C
or a cer;'ifdcata 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.
❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDIADDRESS StJ�
department. (PRINT OR TYPE ONLY)
Avg-
Date Applicant LOCALITY—'
- NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS ST. 44 2QUA
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
SOR
(This section need not be completed if the work involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall -not employ any person in any manner so as to BOILER,BTU
become subject to the Workers' Compensation Laws. Q i
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers' Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL 1 Z2
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY Za
-
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect. /�n
a �-A.1) D
License Number Lic.Class
CL
Contractor Date ,
❑ I am exempt under Sec. Plan Check fee
B.&P.C.for this reason PERMIT ISSUING FEE$ 24
O
Date: TOTAL FEE / LU
Signature co
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT Z
I hereby affirm that I am exempt from the Contractor's License Law NAMEA t/ -
for the following reason (Section 7031.5, Business and Professions A '
Code): ADDRESS rrc+c+�
❑ I, as owner of the property, or my employees with wages D3
as their sole compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale (Section 7044,
Business and Professions Code). OWNER
I, as owner of the property, am exclusively contracting MAIL
s�./f
with licensed contractors to construct the project (Sec- ADDRESSSf-trVI-0—
tion 7044, Business and Professions Code). ;_•I ?':'
CONSTRUCTION LENDING AGENCY CITY TEL.NO.
I hereby affirm that there is a construction lending agency for CONTRACTOR
the performance of the work for which this permit Is issued
(Sec.3097,Civ.C.).
ADDRESS
Lender's Name -sem_i."r,_j`j-i-i l -rf -_•
CITY TEL.NO. :,,n
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 ente upon the above-mentioned
Ifo in a ti poses. _n/ SEE REVERSE FOR EXPLANATORY LANGUAGE
URE OF APPLICANT OR AGENT DATE