HomeMy Public PortalAbout5930 AVON AVE_Mechanical_6/3/1992_floor furnance WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89
,I hereby affirm that I have a certificate of consent to self insure, '76^364° QPPUC^TIO l FOR PCG��i1 T GRE�
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.
Certified copy is filed with the count' building inspection FOR APPLICANT.TO FILL IN BUILDING ��^
/ c��/,
department. y 9 -p (PRINT ORTYPE ONLY)
_ ADDRESS ? Q -z�
:Date Applicant. LOCALITY,.
- - NO;.. TYPE OF APPLIANCE OR EQUIPMENT FEE - �••✓
CERTIFICATE OF,EXEMPTION FROM WORKERS' NEAREST
CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
s section neenot completed if the work involved b ASSESSOR
(Thitid t bc
p y the MAP BOOK PAGE. PARCEL '
,permit is for one hundred dollars($100)or less;) AIR HANDLING UNIT,CFM
DISTRICT NO:'. -PROCESSED BY
I certify that in the performance of.the work fog which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation.Lavis. (J r 0
COMPRESSOR,BTU -
b .APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If.,'after making this Certificate of ROUGH
Exemption,you shoUid become,subject.to.the Workers' Compensation
EVAPORATIVE COOLER
provisions of the Labor-Code;;-.you you must forthwith comply with such FINAL'•
-provisions or this permit shall 6e deemed revoked. FURNACE: FAU Aa(LTY
LICENSED CONTRACTORS DECLARATION / FLOOR BTU '� VALIDATION "
I hereby affirm that-.1 am licensed under,provisions of Chapter 9 SUSPENDED UNIT
,(commencing with Section 7000) of Division 3 of tfie Business and HEATER: WALL
Professions Code,and,,my license is in full force anis effect.
License Number Lic.Class
"Contractor Date O
0.
Plan Check fee V
I am exempt under Sec.
BAP.C.for this reasonPERMIT ISSUING FEE$ Z
- _ W
Date: TOTAL FEE -
W
Signature 0-
'OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT (n
Z
hereby affirm that I am exempt from the Contractor's License Law NAM
-,for the following reason (Section 7031.5, Business and Professions E N D
,Code):. ADDRESS'�� �y
�. 1, as owner,of the property, or my employees with wages .
„; i t_I
structure is not intended or offered for sale (Section 7044;
Business and Profession's Code). • OWNER y - T1
�j, as owner of the property, am,exclusively contracting MAIL t , 730,
With licensed contractors,to construct the project (Sec- ADDRESS
tion 7044, Business.and Professions Code). .
CONSTRUCTION LENDING AGENCY CITY I TEL.NO.
I hereby affirm that there o a'or which
t s lending is iss for CONTRACTOR D "
the performance oft ork•for which this permit Is issued _ - ,_ - •
(Sec.3097,Civ.C.).,..
ADDRESS a
Lender's Name
CITY TEL.NO. a
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 authoriie
repre e�a/Ives o this Co my to enter upon the above-mentioned
prrty br in ection rposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
R OF APPLICA TOR DATE - -. '