HomeMy Public PortalAbout9237 BLACKLEY ST_Mechanical__ WORKER'S COMPENSATION DECLARATION 20 OG46 76A364C DPWs/es APPLICATION FOR PERMIT LNE GREEN
76A364
I +hereby affirm that I have a certificate of consent to self Insure,
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
❑ FOR APPLICANT TO FILL IN BUILDING
Certified copy Is flied with the county building Inspection (PRINT OR TYPE ONLY) ADDRESS
department
Date Applicant NO TYPE OF APPLIANCE OR EQUIPMENTFEE LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NEARESTCROSS ST
COMPENSATION INSURANCE ABSORPTION UNIT BTU
This section need not be completed If the work Involved b ASSESSOR G
( P Y,the ' s• MAP BOOK � �70 PAGE QO� PARCELQ/
permit Is for one hundred dollars($100)or less) AIR HANDLING UNIT,CFM
DISTRICT NO PROCESSED BY
I certify that In the performance of the work for which this permit
Is Issued, I shall not employ any person in any manner so as to BOILER,BTU �O y
become subject to the Workers'Compensation Laws
4V 111ty O ` COMPRESSOR BTU
L— /Y` APPROVALS DATE INSPECTOR S SIGNATURE
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Date Applicant_� VENTILATION SYSTEM
NOTICE•TO APPLICANT If, after making thls'Certificate of ROUGH "
Exemption,you should become subject to the Workers'Compensation - EVAPORATIVE�COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked FURNACE FAU GRAVITY ,
LICENSED CONTRACTORS DECLARATION IFLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and yygLL +
Professions Code,and my license Is in full force and effect /
License Number LIc Class }
O
Plan check fee AC t a
Contractor Date r
ElI _ U
am exempt under Sec _1rJ- -7G Q qcl O
B&P C for this reason PERMIT ISSUING FEE$
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Date TOTAL FEE Q �� TOTAL 30 - 90 d
4 ,
` Signature PLAN CHECK APPLICANT �(�(f; -0.90 Z
OWNER-BUILDER DECLARATION KN
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I hereby affirm that I am exempt from the Contractor's License Law NAME / Q �f ity�� ,�I
for the following reason (Section 7031 5, Business'and Professions �v
Code) ' ADDRESS •
❑ employeess _
I, as owner of the ro ert or m em to ees with wa es t c
as their sole compensation, will dothework and the CITY TEL NO � �I�t��� U' �f�!
structure Is not intended or offered for sale (Section 7044, F,3L2 AMJ0,,-1
Business and Professions Code) OWNER
❑ 1, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec ADDRESS
tion 7044, Business and Professions Code) CITY TEL NO
CONSTRUCTION LENDING AGENCY
I 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 r ,A ,
' CITY TEL NO ,
Lender's Address STATE , - LIC ti
I certify that I have read this application and state that the above LICENSE NO CLASS
Informationcorrect I agree to comply with all County ordinances
�r
and State 1 ws elat 'to building construction,and hereby authorize
represen five Is County to enter upon the above-mentioned
pro ert f sp rposes SEE REVERSE FOR EXPLANATORY LANGUAGE
I lie
2
NA RE A P ICANT AG T DATE '