HomeMy Public PortalAbout5947 AVON AVE_Mechanical_7/13/1995_inlets and outlets WORKER'S COMPENSATION DECLARATION 4 9/69 APPLICATION FOR PERMIT U
' EE33 CCCif��76A3 � GREEN
I hereby affirm that I have a certificate of consent to self insure, 766364C
or a certificate of-Worker's Compensation Insurance, or a certified HEATING -VENTILATING-AIR CONDITIONING'
copy thereof(Sec. 3800 Lab.C.)
Policy-No. Compan 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 BUILDINGdep`aartment. (PRINT OR TYPE ONLY)
Date/ ` ` � Applican NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST �f
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. % AD
COMPRESSOR,BTU �Poo
.. APPROVALS GATE 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 suchFINAL
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provisions or this permit shall be deemed revoked. FURNACE: :F GRAVITY / C? VALIDATION
LICENSED CONTRACTORS DECLARATION FLOOR BTU OC 6�
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 Cod/e,and my license is in full force and effect.
License NumbeLa � Lic.Class18
��Date 6 ' / `1� , Oa
Contract ACCT I a� (�
❑ 1 am exempt under Sec. Plan Check fee ,, Cr.
B.&P.C.for this reason PERMIT ISSUING FEE $ glvo r !TN rISS }..
Date: TOTAL FEE 3 p I;_I I AI z z _ IOU-
CD
Signature PLAN CHECK APPLICANT `:_,hl=.{.•�i 1 S�_1 ,
OWNER-BUILDER DECLARATION
'• 3Pi?_L e
I hereby affirm that I am exempt from the Contractor's License Law NAME ,. t.hrf{;;ti_, ot_i!
for the following reason (Section 7031.5, Business and Professions
Code): ADDRESS
❑ I, as owner of the property, or my employees with wages s ^,i:; i ..
FJ, :1 3u•JU.i .1. _31 7.-
as their sole compensation, will do the work and the CITY TEL.NO. "
structure is not intended or offered for sale (Section 7044, 130-7 { ..
i
1_ : L tii:
Business and Professions Code). OWNER
1, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS ,
tion 7044, Business and Professions Code). CIT ' EL.N ";
Ihereby affirm that there is a construction lending agency for COTR
NACTOR ,.
the performance of the work for which this permit Is issued
(Sec.3097;.Civ.C.).
ADDRESS J
Lender's Name
CITY TEL.NO .4�C,_1141.
Lender's Address STATELIC.
I certify that I have read this application and state that the above LICENSE NO. �i 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 r spe ion p poses. SEE REVERSE FOR EXPLANATORY LANGUAGE
F APPLICANT OR AGENT DATE