HomeMy Public PortalAbout5823 ALESSANDRO AVE_Mechanical__ DECLARAT
WORKER'S COMPENSATION of consent to 76A346DPW9/89 APPLICATION FOR PERMIT LIME GREEN
76A364C
I hereby affirm that I rave a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certifiedHEATING-VENTILATING=AIR CONDITIONING
copy thereof(Sec. 3800 Lab. C.)
Poli 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 ildi ins FOR APPLICANT TO FILL IN BUILDINGHI
x
epartmen (PRINT OR TYPE ONLY) ADDRESS CJ
LOCALITY
Date Applic NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF MP N FROM WORKERS' NEAREST n C
COMPE SA INSURANCE CROSS ST.
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($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU `
become subject to the Workers' Compensation Laws. ��O
COMPRESSOR,BTU
- APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL �•
provisions or this permit shall be deemed revoked. FURNACE: FAU GR ITY ['
LICENSED CONTRACTORS DECLARATION FLOOR BTU &J VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED f UNIT
(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect.
_
�
License Numb ss—�� r �i [i
G /I � 1�I�j•i:'3
Date o
I exempt under Sec. Plan check fee I E`T AL 11411
-�-_p U
B.&P.C.for this reason PERMIT ISSUING FEE$ Q '' �s I. °it O
_�._st�
Date: TOTAL FEE CH A,
KGIE 00,W
Signature CL
PLAN CHECK APPLICANT
OWNER-BUILDER DECLARATION
!W. j' i•` u•
I hereby affirm that I am exempt from the Contractor's License Law NAME 3
for 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.
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
with licensed contractors to construct the project (Sec- ADDRESS Q
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TEL.NO.
I hereby affirm that there is a construction lending agency for CONTRACT ,
the performance of the work for which this permit Is issued
(Sec.3097,Civ.C.).
ADDRESS
Lender's Name
CI Y TEL.NO.&32-
Lender's Address STATE LIC. L d
I certify that I have read this application and state that the above LICENSE NO.&M5 CLASS �.
information is correct. I agree to comply with all County ordinances
and State law lacing to b 'Idin construction,and hereby authori e
represent a of his C ty ent r u bove entio d
ns ctio p r e �^ / SEE REVERSE FOR EXPLANATORY LANGUAGE
I T E OF APL ANT OR NT TE