HomeMy Public PortalAbout9050 ACASO DR_Mechanical_2/20/1996 WORKER'.$rfiNlfxNSATIONDECLARATION 20-0046 DPW 9/89 APPLICATION FOR PERMIT LIME GREEN
76A364C"• '• I '
I here 1 y e:�n that I have a,ertificate of consent to self insure,
or a pe`tltific.�.te of Vyorker's C-rnpensation Insurance, or a certified HEATING -VENTILATING-AIR CONDITIONING
copy thereof(Sec.380PLab.C.)
1'r"
Policy Nb. Company
COUNTY OF LOS ANGELES DEPT-OF PUBLIC WORKS BUILDING AND SAFETY DIV.
F] Certified copy is hereby furnished.
❑
Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDINGADDRESs (�jy
department. (PRINT OR TYPE ONLY)
Date 2 Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS
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($100)or less.) AIR HANDLING UNIT;CFM DISTRICT NO. PROCESSED BY
certify that-in the performance of the work for which this permit et��
is issued, I shall not employ any person in any manner so as to BOILER,BTU r G
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU
APPROVALS DATE INSPE R' IGNATU..
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers' Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR ' 131 �O . VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect. 13
ACCTes
License Number �� Lic.Class ' 3303 5n0 }
1 ITEMS o
Contractor Date ' v
❑ I am exempt under Sec. Plan Check fee TOTAL 58 - 10 U
CHECK 58 010 Cr
B.&P.C.for this real PERMIT ISSUING FEE$ O O
d CHANGE A 00 W
te: TOTAL FEE U
Signature / PLAN CHECK APPLICANT �-y�•y�}{t �'t�1 �y �y (n
O NER-BUILDER DECLARATION 0000-0001 2/20/96 Z
I hereby,affirm th I am exempt from the Contractor's License Law NAMECC��I.� *0
for the following reason (Section 7031.5, Business and Professions Poo.
49?1 1 t I�1�a4
Code): ADDRESS
I, as owner of the property, or my employees with wages / clo 50
as their sole compensation, will do the work and the CITY ~' Ica
Car
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 1)P C%450 l�/1p,
tion 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY Tz/n / 61 T TEL.NO.
I hereby 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.)`�J/ �/
Lender's Name ! X6? ADDRESS
/1_ CITY TEL.NO.
�3 - - - '
Lender's Address %,9(J'Z 1)W STATE LIC. .. ._
I certify that I 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-mentioned
property for 'inspection purpose SEE REVERSE FOR EXPLANATORY LANGUAGE
SI RVI APPLICANT OR AGENT V DATE