HomeMy Public PortalAbout9422 BLACKLEY ST_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89
76A364C APPLICATION FOR PERMIT LIME GREEN
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.)
i 32 "8.3
Policy ho. 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 filed with the county building inspection PRINT OR TYPE ONLY) ADDRESS
• department. (
Date 3 9S—Applicant l�.riiY� LOCALITY Ci.
pp NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST O '
COMPENSATION INSURANCE CROSS ST. (�
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 �A y
�/
become subject to the Workers'Compensation Laws. �^ / (��O
COMPRESSOR,BTU tf Gr
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
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY 0
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED—UNIT—
(commencing
USPENDED UNIT(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code;and my license.is in full force and effect.
License Number &0/ Lic.Class -.
7
a
"
Contract C'
Date `� ' 'T` V
❑ Plan check fee 3303 =�3.:J0
I am exempt under Sec. _ O
B.&P.C.for this reason PERMIT ISSUING FEE $ i L)- L' F–
TOTAL FEE If Date: tq
; W
07
Signature PLAN CHECK APPLICANT C0
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law NAME , CHANGE ,j 13= .
for the following reason (Section 7031.5, Business and Professions
Code): ADDRESS
❑ _ -,
I, as owner of the property, or my employees with wages (,-{�}�1`s_f'!{oI�j f,1`13/95
as their sole compensation, will do the work and the CITY TEL.NO. it
structure is not intended or offered for sale (Section 7044, f:r. J.� 1 •d
32'
Business and Professions Code). OWNER
❑ I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS cie6evS
tion 7044,Business and Professions Code). /
CONSTRUCTION LENDING AGENCY CITY ( (.f TEL. O.
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 /L`
CITY TEL.NO.�7�v0
Lender's Address STATE LIC. �7/ V
I certify that I have read this application and state that the above LICENSE NO. �p 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
Lper,ro_ mspectiour S. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATU OF APPL ANT OR AGENT DATY