HomeMy Public PortalAbout5031ALESSANDRO AVE_Mechanical (2) WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89 `IME GREEN
I hereby affirm that I have a certificate of consent to self insure, 76A364C APPLICATION FOR-PERMIT
or a certificate worker's Compensation Insurance, or a certified HEATING-VENTILATING -AIR CONDITIONING
copy thereof(Sec.3800 Lab. C.) u
Policy No.///9971!9' ompany .�(7 �}/U!3 �/�� 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 BUILDING
dep rtment. (PRINT OR TYPE ONLY)
ADDRESS S o 31 A
Date �? Applicant �RKERS'
NO. TYPE OF APPLIANCE OR EQUIPMENT FEELOCALITYCERTIFICATE OF EXEMPTIO FNEAREST
COMPENSATION INSURANCE ABSORPTION UNIT,BTU CROSS ST.
(This section need not be completed if the work involved by the ASSESSOR
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM MAP BOOK PAGE PARCELDISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to I BOILER,BTU P _-
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU C/
APPROVALS DATE - INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER v
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU / VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and HEATER:
WALL
Professions Code,and my license is in full force and effect.
License Number S 7�'� Lic.Classy
W AT ,.,�
Contractorjoctl0 _A/A-/(� Date 3 O�'�
F-1U
0
I am exempt under Sea Plan check fee
6.8P.C,for this reason PERMIT ISSUING FEE$ gp
Date: TOTAL FEE LLI
Signature coIL
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT Z
I hereby affirm that I am exempt from the Contractor's License Law NAME �� �,� , <r
for the following reason (Section 7031.5, Business and Professions 6
Code): C // 11 (
F-1 1,
Z �7 �l ?G-�--Y A/C_1 c) J: LI_
I, as owner of the property, or my employees with wages w=tr ; j:_
as their sole compensation, will do the work and the CITY UJ TEL.NO. d�
structure is not intended or offered for sale (Section 7044, OO 'r (rL
Business and Professions Code). OWNER
❑ I, as owner of the property, am exclusively contracting O T AL Oct
MAIL
with licensed contractors to construct the project (Sec- ADDRESS /� a,O;.E�. ��yp�
tion 7044, Business and Professions Code). C.,E K
CITY TEL.NO. ;�'AFJ:-r"
CONSTRUCTION LENDING AGENCY �/rJ�-2 . L�t,4i�L
I hereby affirm that there is a construction lending agency for r\ ,
the performance of the work for which this permit Is issued CONTRACTOR �t AJA
(Sec. 3097,Civ. C.). f/T
ADDRESS - 4S'.
I Z ;U1 0/�.41i
Lender's Name CITY TEL.NO. ?hJ 7o
Lender's Address STATE ' [ LIC.
certify that I have read this application and state that the above LICENSE NO. '� (, y� CLASS C z.C)
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
pro erty for inspectio rposes. / SEE REVERSE FOR EXPLANATORY LANGUAGE
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SIGNATLIOF APPLICANT NT DAT