HomeMy Public PortalAbout9058 ACASO DR_Mechanical_5/18/1992 A WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89
76A364C APPLICATION FOR PERMIT Le E GREENI hereby affirm that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified HEATING -VENTILATING -AIR CONDITIONING
copy thereof(,Sec. 3800 Lab.C,.)
Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
BUILDING
❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN ADDRESS
department. (PRINT OR TYPE ONLY) 0
Date ApplicantLOCALITY
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 ASSESSOR
( ib p y the MAP BOOK PAGE G)_t PARCEL O I
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU R- 3
become subject to the Workers' Compensation Laws.
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM n
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH 5IXa
Exemption,you should become subject to the Workers' Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL'
provisions or this permit shall be deemed revoked. FUACE: F U GRAVITY
LICENSED CONTRACTORS DECLARATION FLOORNR BTU 3jL-6"ab VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATERSUSPENDED UNIT
:
(commencing with Section 7000)of Division 3 of the Business and WALL
.Professions Code,and my license is in full force and effect.
License Number Lic.Class
Contractor Date , O
❑ I am exempt under Sec. Plan Check fee O
B.&P.C.for this reason PERMIT ISSUING FEE$ >74 7
Date: TOTAL FEE q d
Signature (n
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT Z
1 hereby affirm that I am exempt from the Contractor's License Law NAME
for th
e
following reason (Section 7031.5, Business and Professions , r.•.
ADDRESS
I, as owner of the property, or my employees with wages
their sole compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale (Section 7044, \ _s
Business and Professions Code). OWNER 0
I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS Achgo a-i've
tion 7044, Business and Professions Code).
CITY \ TEL.NO. '�`��"'�
CONSTRUCTION LENDING AGENCY Q I Ci is
hereby affirm that there is a construction lending agency for CONTRACTOR ,
the performance of the work for which this permit Is issued b�
(Sec.3097,Civ. C.).
ADDRESS •,_;. -,:•r, _. s..»
Lender's Name
CITY TEL.NO. -r s
Lender's Address 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
prop ty for i spection purpose SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF P LICANT OR AGENT DAT