HomeMy Public PortalAbout5420 ACACIA ST_Mechanical_2/22/1993_compressor, floor furnance, inlets WORKER'S COMPENSATION DECLARATION 46DPW 9/89 APPLICATION FOR PERMIT LME GREEN:
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hereby affirm that I have a certificate of consent to self insure, 76A364C
or a certificate of WorkeP's Compensation Insurance, or a certified HEATING-VENTILATING -AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.) LJ
Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS. BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
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Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN nooaESS 20 ( j
department. (PRINT OR TYPE ONLY)
LOCALITY
Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST CROSS /�1/
4-P /W
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COMPENSATION INSURANCE CROSS
ABSORPTION UNIT,BTU ASSESSOROR ST. l7
(This section need not be completed if the work involved by the MAP BOOK S-39-9 PAGE 024- PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU6
become subject to the Workers'Compensation Laws. / —,q Q
COMPRESSOR,BTU 0 7 O
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH �3
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL ry-zl 7
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU e12�, DO O Q VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect.
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License Number Lic.Class �. ��_e-4�,
Contractor Date OU
I am exempt under Sec. Plan check fee cc
B.&P.C.for this reason PERMIT ISSUING FEE$ i F-
Date: TOTAL FEE ACCI ■1r U
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Signature �I�7 1132.15i co
CHECK APPLICANT
OWNER-BUILDER DECLARATION7 Z
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I hereby affirm that I am exempt from the Contractor's License Law NAME i ITEMS
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for the following reason (Section 7031.5, Business.and Professions , ��t�,3 _
coo1*171 ): ADDRESS TOTAL
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I, as owner of the property, or my employees with wages CHECK 102.75
as their sole compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale (Section 7044, CHANGE .1313
Business and Professions Code). OWNER -T-k" V A-J `�j'�
DI, as owner of the property, am exclusively contracting MAIL l'� !
with licensed contractors to construct the project (Sec-. ADDRESS �,�_.7 �,a.
tion 7044, Business and Professions Code). CITY TEL.NO. 0.312 1 AM
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44.;
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CONSTRUCTION LENDING AGENCY
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.).
ADDRESS
Lender's Name
CITY TEL.NO.
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
property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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SIGNATURE OF APPLICANT OR AGENT DATE