HomeMy Public PortalAbout6273 AVON AVE_Mechanical_2/25/1992_furnace and ducts WORKER'S COMPENSATION DECLARATION 46DPW 9/89 APPLICATION-FODR PERMIT LI E GREEN,
76A3
I hereby affirm that I have a certificate of consent to self insure, 76A364C
or a certificate of Worker's Compensation Insurance, or a certified HEATING -VENTILATING-AIR CONDITIONING
copy thereof'((SSec�.3800P Lab.C.)
Policy No.J�L Company v COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
!rfified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING. a
(PRINT OR TYPE ONLY) ADDRESS en ^�] LOCALITY t
Date Applicant !r NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
(This section need not.be completed if the work involved by the MAPESSOR 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. 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: GRAVITY
a 3 A5' V (DATION
LICENSED CONTRACTORS DECLARATION FLOOR BTU '7G�
I hereby affirm that I am licensed under provisions of Chapter 9 HEATERSUSPENDED UNIT
:
(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect.
_ 6 bJ.X3 a
License Number 2- V Lic.Class
Contractor '""�'—~ Date 1Zt�j `�� , 0
❑ I am exempt under Sec. Plan Check fee 0
Q
BAP.C.for this reason PERMIT ISSUING FEE $ 0
Date: TOTAL FEE W
Signature _ a_
PLAWCHECK APPLICANT v
OWNER-BUILDER DECLARATION r 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 _^'•.1i _ -
❑ I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL.NO. x = �
structure is not intended or offered for sale (Section 7044, t
Business and Professions Code). OWNER }t s^ s k-.€F_J
I, as owner of the property, am exclusively contracting MAIL 1 w•` f"` =_"=
with licensed contractors to construct the project (Sec-
ADDRESS
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TEL.NO.
Ihereby affirm that there is a construction lending agency for _
the performance of the work for which this permit Is issued CONTRACTOR
(Sec.3097,Civ.C.). f
ADDRESS 0 S
i i t .t
Lender's Name l _'i'.'
CITY /y�)D 'U J r TEL.NO.
Lender's Address STATE • ,v,cv� LIC.
I certify that l have read this application and state that the above LICENSE NO. CLASS
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- ntioned
property for ' spection SEE REVERSE FOR EXPLANATORY LANGUAGE
i
SIGNAT OF APPLICA R AGENT DATE