HomeMy Public PortalAbout5745 ALESSANDRO AVE_Mechanical__ -! WORTCER'SCOMPENSATION DECLARATION 46DPW 9/89
76A364C APPLICATION FOR PERMIT
76A3
I hereby affirm that I have a certificate of consent to self insure, LIME GREEN
or a certificate of Worker's Compensation Insurance, or a certified HEATING -VENTILATING-AIR CONDITIONING
copy thereof 3800 Lab. C.)
vJaio�t�4c6oz WJ�'f�D AC��cti1'Lit;S
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 count buildinginspection FOR APPLICANT TO FILL IN BUILDING
department. y (PRINT OR TYPE ONLY) ADDRESS S� S A4_.LA D
Date 8 J "�I Applicant LOCALITY
or NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST �v�K
CROSS ST.
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($100)or less:) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not,employ any person in any manner so as to BOILER,BTU �
become subject to the Workers'Compensation Laws. !
_ COMPRESSOR,BTU I Z oe�
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH 3
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL' .
provisions or this permit shall be deemedrevoked. I FURNACE: FAU_ZLGRAVITY I^ VALIDATION
LICENSED CONTRACTORS DECLARATION FLOOR BTU Ii
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED-UNIT-
(commencing
USPENDED UNIT(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect.
C /
License Number SrolSCv Lic.Class G ZC>
CL
Contractor IVAi801 ate el `1 (,
I am exempt under Sec. Plan check fee o
B.&P.C.for this reason PERMIT ISSUING FEE$ ba U
Date: TOTAL FEE 5 T Do LU
Signature - PLAN CHECK APPLICANT co
OWNER-BUILDER DECLARATION Z
I hereby affirm that I am exempt from the Contractor's License Law NAME pop
the following reason (Section 7031.5, Business and Professions
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. ;` yF
structure is not intended or offered for sale (Section 7044, _v_fr a€.`
Business and Professions Code). OWNER 1 T,;yj'I
❑ I, as owner of the property, am exclusively contracting 5^-s 0
MAIL ;?_i F? I_ __9 dr as
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code). °•i"� `.t: :Ir aI_lyi
CITY TEL.NO.
CONSTRUCTION LENDING AGENCYt-- I'•.
hereby affirm that there is a construction lending agency for '-'H�'NGiI a:).'
the performance of the work for which this permit Is issued CONTRACTOR
(Sec.3097,Civ.C.).
ADDRESS
�� ...7 T L�1 1�3� (_...Es}l f'•'I!'�i.i. r L`: .f.
Lender's Name ���± _
CITY �.1rti .a A TEL.NO. �I� A'[CG :.`I�i a 1'sr,3liie.`
Lender's Address STATE LIC.
I certify that I have read this application and state that the above LICENSE NO. 'S5 ;, 5cp CLASS Zo
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
pro A
rty for insp ct'on purpo es. SEE REVERSE FOR EXPLANATORY LANGUAGE
-3a-9/
SI NATURE APPLICANT OR AGENT DATE