HomeMy Public PortalAbout6148 AVON AVE_Mechanical__ t4 WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89 APPLICATION FOR PERMIT
LIME
L� E GEE
I hereby'affi;m that I.have a certificate of consent to self insure,
or jrcertificAte of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec. 3800 Lab. C.) L�
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 'DDR 33
department. (PRINT OR TYPE ONLY) 641. A o �V
Date Applicant LOCALITY ®N
N0. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE ABSORPTION UNIT,BTU CROSS ST.
(This section need not be completed if the work involved by the ASSESSOR
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM MAP BOOK PAGEbp PARCEL
DISTRICT NO. PROCESSE aV
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU 2�
APPROVALS DATE NSPECTOR'S SIGNATURE
Date —S—Te Applicant �' VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH � � f
Exemption, you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAUGRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU �j Z VA I ATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect.
OUTLETS c�- (Mi-t-ETS
License Number d4l _?J?R Lic.Class
Contractor A U- 6:412)U S! Date❑ U Plan check fee
am exempt under Sec. e
BAP.C.for this reason PERMIT ISSUING FEE$
U
Date: TOTAL FEE -7 _• ' - .7. ;::f' a
Signature N
PLAN CHECK APPLICANT TT=111"'
OWNER-BUILDER DECLARATION - = — Z
hereby affirm that I am exempt from the Contractor's License Law NAME
for the following reason (Section 7031.5, Business and Professions s
Code): ADDRESS �' ='
El1, as owner of the property, or my employees with wages f9 ' `I -f r _ ;•) ,
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 f'stusmrti
+ Tct+ewj
I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS '?
Ti i -
tion 7044, Business and Professions Code).
CITYTEL.NO.
CONSTRUCTION LENDING AGENCY L d
1hereby 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.). Ib 1111,31
ADDRESS
Lender's Name
CITY C TEL.NO.
Lender's Address STATE LIC. 54
I certify that I have read this application and state that the above LICENSE NO. CLASS La
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
property for in p ction purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APP ANT OR AGENT DATE