HomeMy Public PortalAbout10637 BOGUE ST_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046 DPW g/gg' APPLICATION, FOR PERMIT
76A364C L E G,.,R,.E.EN :l
hereby affirm that-1 have a certificate of consent to self,insure, _ _
2.
or'a certificate of Vorker's Compensation Insurance, or a certified ", HEATING,-VENTILATING •CONDITIONING
copy thereof;(Sec 3800,Lib C.) j
Policy No Company COUNTY OF LOS,-ANGELES DEPT.•OF PUBLIC WORKS'- BUILDING•AND SAFETY DIV. ,
Certified copy Is hereby furnished. '
Certified co Is filed with the count building inspection FOR APPLICANT-TO'FILL IN BUILDING / �
❑ PY Y 9 P ADDRESS �4 �,.,`
+ department. (PRINT OR TYPE-ONLY) 'r
Dater Applicant ' LOCALITY s y
NO TYPE OF APPLIANCE OR,EQUIPMENT •FEE
w*"
NEAREST. '
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST 1
-COMPENSATION INSURANCEUN
ABSORPTION IT;BTU-
ASSESSOR'' e- '
(•This.section need not be completed if the'work involved by.the MAP BOOK �' PAGoOy PARCELi?"
rm
peit is for one hundred dollars($100)-or,less.) AIR HANDLING UNIT,CFM
DISTRICT NO - PRO ESS
ED BY
I^certify that in the performance of,the work for which this'permit , �a
Is issued, I.shall-hot employ'any'person in any anner so as to• BOILER,BTU h
become subject to the Workers' Compensam
tion Laws
COMPRESSOR,BTU - ' • • , - ''
' Date • !i Ijcant APPROVALS DATE t •INSPECTOR'S SIGNATURE' -
PP - VENTILATION"SYSTEM ' a - ,-
NOTICE.TO APPLICANT If,'after making this Ce}tificate;of ' ROUGH ��- _O G• <
Exemption;you should become subject to-the Workers'-Compensation EVAPORATIVE CbOLER
;t'provisicns,of the Labor"Code;`you-must forthwith coniply:with such + FINAL
provisions or this permit shall be deemed revoked FURNACE::•.: ''FAU GRAVITY'
LICENSED CONTRACTORS DECLARATION FLOOR, --BTU-''' a,VALIDAT.ION
I,hereby•affirm that I am licensed under provisions of Chapter 9 'SUSPENDED-_- UNIT "
(comencing with Section 7000) of Division of We Business and HEATER
m & WALL
Professions Code, and'my license is in full force and effect
License Number. Lie.Class a
-Contractorf330,
Date Q
Plan check fee. n �_IT,i _£-J �..
exempt under Sec: I f.I fe ,-rO
B.&P.0 for this reason J, PERMIT ISSUING FEE$ �j/p (_y C };e+
• .
Date: TOTAL FEE
Signature PLAN CHECK APPLICANT,
" OWNER-BUILDER DECLARATIONZ
hereby affirm.that I am exempt from the Contractor's License Law ME-' '_j'i ly, .• I'j=r;:` y;
.,for the following reason (Section 7031.5,`Business and Professions
:�_
Code):
ADDRESS,, c
.t
❑ I, as owner of the.property,,oe*my employees-witti wages 1
as-their sole 'Will,do the work and the CITY TEL NO
structure Is not intended or offered for sale (Section-7044, '
Business and Professions-Code).
❑ I as-owner of the'property, am"exclusively contracting,, MAIL
,with,,.licensed contractors to,construct the project (Sec- ADDRESS' "
tion 7044, Business'and Professions Code)
CITYTEL NO "
CONSTRUCTION LENDING AGENCY M ,
I••HEireby'affirm that there Is a construction lending:agency for , CONTRACTOR T
the performance of the work for which-this permit is issued - -�
(Sec.3097,Civ. C). " -
�� ADDRESS
Lender's,Name 7
> CITY TEL,NO , #a
4 Len ldr's Address_' STATE LIC.
certrfy'that I'.have read this apphcati and state that the above LICENSE NO CLASS r
information is correct. I agree to comply with all'County ordinances
and State laws relating td budding construction,and hereby authorize
representatives-of this County to enter upon the above-mentioned V
property inspection ses. SEE REVERSE FOR EXPLANATORY LANGUAGE,
GNAT.RE OF AP ANT OR AGE DATE -