HomeMy Public PortalAbout10646 BOGUE ST_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89
76A364C LIME-, ,GREEN
• Thereby affirm that I have a certificate of consent'to self insure, 'APPLICATION FOR"PERMIT.
or a.certificateof Worker's Compensation Insurance, or a certified VE
or AIR CONDITIONING
copy thereof,(&c •3800 Lab C)
Policy No' 1 � Company �� ;COUNTY OF LOS„ANGELES DEPT.OF PUBLIC WORKS BUILDING AND SAFETY DIV. LLLIII
❑ Certified'copy Is hereby furnished.
certified copy ie fled with'the couniy'tiuildmg Inspection' FOR APPLICANT TO FILL IN ADDRESS �6T6. �0(Tk�
• BUILDING
department 1 ,•• (PRINT OR TYPE ONLY)
LOCALITY,
Date f.z"�I Applicant NO TYPE OF APPLIANCE'OR EQUIPMENT 'FEE C Ir
NEAREST
CERTIFICATE OF•EXEMPTION FRO WORKERS' CROSS-ST. McI{]Z': > a• •-
COMPENSATION INSURANCE
ABSORPTION UNIT,BTU' ASSESSOR
(This section need not be completed if the,work involved by the MA_P BOOK, PAGE PARCEL
permit,is,for one hundred dollars($100)or,less:) _ AIR HANDLING UNIT,_CFM`' Y
' DISTRICT NO PROCESSED.BY
I certify-that in'the performance of the work for which this permit
Is Issued-, ('.-shall hot'employ any person In any manner so as to BOILER,BTU n �/
become subject to;,6e Workers' Compensation,Laws v`O
COMPRESSOR,BTU-
_ -APPROVALS -DATE'�' INSPECTOR'S SIGNATURE,
Date Applicant VENTILATION SYSTEM', =
NOTICE.TO APP u' CANT.: If;-after making this Certificate of ROUGHr
Exemption,.you should,become-subject tc the Workers''Compensation i
EVAPORATIVE COOLER.., FINAL:
provisions of the Labor Code, you'md'st'forthwith;comply wrth,such
a.provisions or this permit shall be deemed revoked. FURNACE FAU GRAVITY ;
LICENSED CONTRACTORS.DECLARAT!ON FLOOR BTU ALID TION.,.
hereby affirm that`I,arn licehsed under provisions-of Chapter 9 SUSPENDED UNIT.
(commencing,with Section 7000) of,Division 3 of the Business and HEATER: WALL ”
Professions Code,'and'my'license is in full force and effect o
dL aq4_nil. (4 CT OD
Llcense.,Numtier - L'Ic.'Class
Contractor Date O
❑ I am ezem under Sec. Plan'Check"fee V
cc
B&P.0 for'this reason 'PERMIT ISSUING FEE'$ 0
Date, TOTAL FEE Dom' U.
s-.
Signature - PLAN CHECK`APPLICANT' ' '-• -- C0
OWNER-BUILDER DECLARATION 7j3, $;- Z
I hereby affirm that I am exempt from the�Contractor's License Law NAME
for the follow_Ing'.reason (Section•7031 5, Business and Professions
Code) ADDRESS
❑ 1, as Owner of the property, or.rriy employees`with wages
as their sole compensation; will do'dhe,.work and the CITY TEL NO ,
' ' -1-1
r,.=
structure-ii not intended or offered for-sale (Section'7044,
Business'and,Professions Code). OWNER ►9~hy �'j1�,s S (�
`-❑ I, as owner of the property, am exclusively contracting MAIL )L E ® § '
with licensed contractors to construct the project (Sec-"' ADDRESS X6"[6 g�GkE' ;`
" tion,7044„Business and Professions Code). . . ,'iJU '
CITY .D� j TEL'NO.•;Lt '
CONSTRUCTION LENDING AGENCY, /' 1 ” { i it '
I hereby affirm that there.is a construction lending agency for �p " • :' ' ' °' �.'-
the.,perforrhance•of'the work for which'this permrt.•is.issued CONTRACTOR
(Sec:3097,Civ.C.).
i,
�AODREss a i ,if;l_—i�;iI'a
Lender's Name
CITY - ,TEL,NO. A5+ 1 >10_';.[ ,
Lender's Address STATE LIC(.•
certify that'(".have read this application and state that the above LICENSE NO' � '3 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 ti .
property;fo nspection purposes. SEE REVERSE FOR'EXPLANATORY LANGUAGE .
SIGNATURE OF APPLI A OR AGENT - DATE