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Home My Public Portal About10538 DANBURY ST_Mechanical_6/25/1993_ventilation system WORKER'S COMPENSATION DECLARATION 20.00411 DPW 9/89 APPLICATION FOR PERIViIT �pI{I �/p� GREEN ,]6A364C L�4 M E GREE N I hereby affirm that I have a certificate of consent to self insure, '� LL�� or a certificate of Workers 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. ❑ ' Certified co is filed with the count building inspection FOR APPLICANT TO FILL IN BUILDING 1053 t7 PY Y 9 P ADDRESS JJO department. - (PRINT OR TYPE ONLY) Dale ApplicantLOCALITY ' F /1/ E �I T - NO. TYPE OF APPLIANCE OR EQUIPMENT FEE TGG/��/r/�1� ST -' CERTIFICATE OF EXEMPTION FROM WORKERS' - GROSSNEAREST Si. P4 MA'L )"WE COMPENSATION INSURANCE ABSORPTION UNIT,BTU This section need not be completed If the work involved b the ASSESSOR " I P Y MAP BOOK PAGE PARCEL permit is for one hundrederforr antes f the or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PPOCESaEO BY I certify that in the�pertormance et the work for which this permit is issued, 1 shall not employ any person in anymanner so as to BOILER,BTU o �/� � ) become subject to the Workers'Compensation Laws. , ,�O `ZGi'�'��/' COMPRESSOR,BTU Date - Applicant < VENTILATION SYSTEM APPROVALS DATE wsPE�Ps sisunruPE ' NOTICE TO APPLICANT: If, after making this Certificate of •" • r ROUGH - Exemption, you Should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code, you must forthwith comply with such FINAL r 3 .provisions or this permit Shall be deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU _ 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. License Number Lia Class IL ContractorDate - r 44[L O ❑. I am exempt under Sec. PIBD.Check fee ... 330-6 _ "/�I Q B.BP.C.for this reason ' PERMIT ISSUING FEE$ 1 1TEP!c O Date: TOTAL FEE TOTAL 69 . 30•w Signature :HEY:`� N OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT - •�If4 Z CHAHGE` _:__ I,hereby affirm trial I am exempt from the Contractor's License Law NAME D. for the following'reason (Section 7031.5,.Business and Professions Co e): ADDREss `""K I,,as owner of the property, or my employees with wages i 'A�,hfd1 as their sole compensation,'will do,the work and the CITY TEL.NO. ; 0461 1"" AM �,•p`, V•J. structure is not intended or offered for sale (Section 7044; - -- Business and Professions Code). '. OWNER /T k9-MA!7 A"M Q V/�f} N IC . F-1 1, as owner of the property, am exclusively contracting MAIL _ with licensed contractors to construct the project (Sec- ADDRESS 10_536 - tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY" CITY 'T El11F'LE /) -TJ TEL. 3Jr-�..7�'� 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 relati building construction,and hereby authorize " representatives of Unty toenter uponthe above-mentioned property for in purposes.. ^ - �) SEE REVERSE FOR EXPLANATORY LANGUAGE - GIGNATUREOFAPPLICANT AGENT DATE