HomeMy Public PortalAbout4841 ARDEN DR_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-00 4C
46 DPW 9/89 APPLICATION FOR PERMIT LI E GREEN.
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I Fereby 1.affirm that I have a certificate'of consent to self insure, 76A3
or a certificat&,6f Worker's Compensation Insurance, or a certified HEATING-VENTILATING -AIR CONDITIONING
copy thereof(Sec. 3800 Lab. C.)
Policy N `/J'16 mpany H` < 5� COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN BUILDING r b Y
Certified copy is filed with the cou tiding inspection PRINT OR TYPE ONLY ADDRESS j T
depa ent. ( )
Date I Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST
CERTIFICATE OF EXEMPTIO ROM WORKERS' 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($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU
APPROVALS DATE INSP OR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL l tZ
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAV TY VALIDATION
LICENSED CONTRACTORS DECLARATION FLOOR BTU
hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect.
License Numb e Lic.Class `�
0.
Contractor ate �/ Z U
Plan check fee U
I am eU pt der Sec. cr_
B.&P.C.for this reason PERMIT ISSUING FEE$ �3 p p O
U
Date: TOTAL FEE O - W
i�
Signature PLAN CHECK APPLICANT co
OWNER-BUILDER DECLARATION Z
I hereby affirm that I am exempt from the Contractor's License Law NAME ,
for the following reason (Section 7031.5, Business and Professions
Code): ADDRESS
ANI
El1, as owner of the property, or my employees with wages _ �.1 �F
as their sole compensation, will do the work and the CITY. TEL.NO. L=L}r
structure is not intended or offered for sale (Section 7044,
Business and Professions Code). OWNER n Oaoi-v--
❑ I, as owner of the property, am exclusively contracting 1 E•}t
MAIL ff�� J L A
f� 1 AL. _ 7 - 0
with licensed contractors to construct the project (Sec- ADDRESS Q Q G,
tion 7044, Business and Professions Code). CHEC
.•:
CITY k TEL.NO. T_ — 'I
CONSTRUCTION LENDING AGENCY VVV 111 J s;c 11�SSC
I hereby affirm Ahat there is a construction lending agency for ^ 1 ,
the performance of the work for which this permit Is issued CONTRACTOR
(Sec.3097,Civ. C.).
ADDRESS ' li c "`''•" �, CI[1k13!—G-010,
Lender's Name ✓
TEL ¢Q m t '
CITY a�t t .NO. '3j�1 I O Q' 1'4
Lender's Address STATE LIC. V
I certify that I have read this application and state that the above LICENSE NO. ab 39 CLASS C-
information is correct. I agree to comply with all County ordinances
and State I s relating to,building construction,and hereby authorize
represe ves of this County to r upon the above-mentioned
proper f in pectin es. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APPLICANT OR AGENT DATE