HomeMy Public PortalAbout5731 ALESSANDRO AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89
76A364C. APPLICAIrION FOR PERMIT ( �ijl ,'al� '� _
I hereby affirm that I have'a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified HEATFIG- '(ENTILATING-AIR CONDITIONING IL QUI
copy thwoof Sec. 3800 Labs.Com.)',
Policy No. ���3��'Edmpany COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished. 7—
BUILDING El
tified copy is filed with the county buil I pection FOR APPLICANT TO FILL IN ADDRESS
art 7/Jnt.
(PRINT OR TYPE ONLY)
Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
CERTIFICATE OF EXEMPTION FR/OM WORKERS' NEAREST
COMPENSATION INSURANCE ABSORPTION UNIT,BTU CROSS ST. 0
ASSESSOR
(This section need not be completed if the work involved by the MAP BOOK, PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU o
�� j1
become subject to the Workers'Compensation Laws. 4 �f✓ G %����
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL 1' -
provisions or this permit shall be deemed revoked. FU ACE: FAU GfgA)9TY / VALIDATION
LICENSED CONTRACTORS DECLARATION OORI BTU
1 hereby affirm that 1 am Licensed under provisions of Chapter 9 SU ENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and HEATER:
Professions Code,
`7and my license is in full force and effect.
License Number Vy2 Lic.Class
/yam • A a� �i ® 3303 53.40 0
�S'
Contractor �W L'-'-' Date i
❑ I am exempt under Sec. Plan Check a TOTAL ITEMS 6
=-.A3 m 40p
B.&P.C.for this reason PERMIT IS NG FEE$ (f CASH e4 U
Date: TOTAL FEE CHANGE .00 a
Signature co
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT Zftt��f
000
I hereby affirm that I am exempt from the Contractor's License Law NAME , 0 - 1
for the following reason (Section 7031.5, Business and Professions tt111i 11 7
Code): ADDRESS
❑ I, as owner of the property, or my employees with wages
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 �1'�l.e --✓lr�s
❑ I, owner of the 'property, exclusively contracting MAIL
withh co licensed contractors to construct the project (Sec- ADDRESS
tion 7044,Business and Professions Code). /
l� ���
CONSTRUCTION LENDING AGENCY CITY TEL.NO
ri vci
1 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,7a
Lender's NameO
' CITY G� TEL.NO. �
Lender's AddressSTATE / LIC. /r
I certify that I have read this application and state that the above LICENSE NO. 6�iZ O CLAS C/
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
representative f this County to enter upon the above-mentioned
proper for spection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SI NATURE F APPLICANT OR AGENT DATE