HomeMy Public PortalAbout5937ALESSANDRO AVE_Mechanical WOR,KER'SCOMPENSATION DECLARATION 20-0046 DPW 9/89 APPLICATION FOR PERMIT
I hereby,dftlrfTl 76A364C that I have a certificate of consent to self insure, L��X� ,y
or a certific;fe,10 Worker's Compensation Insurance, or a certified HEATING-VENTILATING -AIR CONDITIONING LLL��� RE
copy thereof S-c.35800_ Lab,. C.)
Policy No.�Company s&& ii •& COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. LLL111
❑� Certified copy is hereby furnished.
19 copy y g inspection FOR APPLICANT TO FILL IN BUILDING
Certified co Is filed with the count building department. ,' (PRINT OR TYPE ONLY) ADDRESS
Date �� k1-Q� Applicant r � �� LOCALITY �
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE �.i.
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCEi /D CROSS ST.
ABSORPTION UNIT,BTU �Y (O ASSESSOR �pr�
(This section need not be completed if the work.involved by the MAP BOOK e.:5—d'7 PAGE 100,1 PARCEL OOS
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE!! /
Date Applicant VENTILATION SYSTEM �'.
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH J 1
Exemption,you should become subject to the Workers' Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with suCP FINAL _
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR _BTUjffC DMO .1/., /o VALI ATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect. /
License Number �qq� 1 Lia Class W
Contractor ,Date =i • •i a D_
❑ I am exempt under Sec. Plan Check fee 11J: 9'.20 O
cc
BAP.C.for this reason PERMIT ISSUING FEE$ _ €`� 0
Date: TOTAL FEE `0 V
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g
Si nature PLAN CHECK APPLICANT fn C qr R_.j: '1 a•2�F a
OWNER-BUILDER DECLARATION (.:Hf+:NGE .00 z
I hereby affirm that I am exempt from the Contractor's License Law NAME oil"
the following reason (Section 7031.5, Business and Professions t''a!) VL
Code):
❑ ADDRESS 1�® rt 014'j = f =a:I
I, as owner of the property, or my employees with wages O r ` 000 7t�f� r% s�/
as their sole compensation, will do the works and the CITY TEL.NO. I_ '�• 'C
T 1 iir
structure is not intended or offered,for sale (Section 7044,
Business and Professions Code). OWNER
I, as owner of the property, am exclusively contracting MAIL `
with licensed contractors to construct the project (Sec ADDRESS (�w�
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY EAM TEL.NO. _
I hereby affirm that there is a construction lending agency for NTRACTOR ,
the performance of the work for which this permit Is issued
(Sec.3097, Civ. C.).
ADDRESS oo
Lender's Name V
CITY C"Q TEL.NO. O
Lender's Address STATE LIC. L
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
�9t9NA� RE OF: APPLICANT OR AGENT DATE
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