HomeMy Public PortalAbout9217 BLACKLEY ST_Mechanical__ t WORKER'SCOMPENSATION DECLARATION 20-0046 DPW 9/69 APPLICATION FOR PERMIT LIME GREEN
I hereby affirm that I have a certificate of consent to self insure, 76A364C
or a certificate of Worker's Compensation Insurance, or a certified
HEATING-VENTILATING -AIR CONDITIONING
copy theieof+(Sec.3800 Lab. C.)
'
Policy Np. Company 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 BUDREss Z &ZA C f
department. (PRINT OR TYPE ONLY)
Date ApplicantLOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS
COMPENSATION INSURANCE
ABSORPTION UNIT,BTU ASSESSOR
(This section need not be completed if the work involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU Y r
become subject to the Workers'Compensation Laws.
�`y/J -/7�� ( COMPRESSOR,BTU
Date S�Z / Applicant ` �%y�? `"f�L VENTILATION SYSTEM APPROVALS DATE INSPECTOR'S SIGNATURE
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH 3
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER 17
provisions of the Labor Code, you must forthwith comply with such ;417771-1 J7 FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU` GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED-UNIT
(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect.
License Number Lic.Class % � ��
Contractor Gyr ti yl� f6��LDate j�// / poll. 0
❑ I am exempt under Sec. Plan check fee U
B.&P.C.for this reason PERMIT ISSUING FEE$ 0
-Date: _t—A )H/ TOTAL FEE 037,,go W
Signature (L
�- �/�L/'J 4�-r (-
/ PLAN CHECK APPLICANT U)
OWNER-BUILDER'DECLARATION
Z_
I hereby affirm that I am exempt from the Contractor's License Law NAME ,
for the following reason (Section 7031.5, Business and.Professions -
Code):
❑ ACADDRESS t"r''�' �
I, as owner of the property, or my employees with wages ,C t
as their sole compensation, will do the work and the CITY TEL.NO. wi$^ 5711° SI-i
structure is not intended or offered for sale (Section 7044,
Business and Professions Code). OWNER s 1_F MI
❑ _ ..
I, as owner of the property, am exclusively contracting
MAIL �� 1 iiL 55 . 00
with licensed contractors to construct the project (Sec- ADDRESS Z l s
tion 7044, Business and Professions Code). CHECK
CONSTRUCTION LENDING AGENCY CITY Z TEL NO17
p.,, _
I hereby affirm that there is a.construction lending agency for �' R#t'
the performance of the work for which this permit Is issued CONTRACTOR lfCf D e fo `,� ,,
(Sec. 3097, Civ. C.). /
ADDRESS Grp f � _ _ .
� r � 01001-D-9100-1
'I���;F�eZ
Lender's Name - '�- 1-1 `=�-1 -Ef2^=��5=
CITY TEL.NO/y��J /�L-91J�6 ;�; } -t•t :;:•;,
Lender's Address STATE / r LIC. ,N
I certify that I have read this application and state that the above LICENSE NO. fi 6.� b CLASS 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
property�f%inspection purpgses�- l SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APP I(,ANT OR AGENT / DATE