HomeMy Public PortalAbout9528 BOGUE ST_Mechanical__ WORKER'S COMPENSATION DECLARATIG '' 20-0046 DPW 9/89 APPLICATION FOR PERMIT
76A364C . . : L I E. ' ',GREEN'
I hereby affirm that I have'a certificate of consent to self Insure,
or a certificate-of Worker's,C6mpensation Insurance, or-a-'certified' HEATING -VENTILATING-AIR CONDITIONING'
copy"thereof(Sec 3800 Lab C.)
7 r - - _ , �•
Pohcy-No,/ :Company�1' ; /�C� 'COUNTY OF-LOS-ANGELES DEPT'OF PUBLIC WORKS. BUILDING AND SAFETY,DIV: ,
r,k,
r Certrfied copy Is hereby furnished.. _ N
BUILDING
/Certrfled,co Is,flled with the count building inspection k= " FOWAPPLICANT,TO FILL IN
PY^ Y 9 p ADDRESS• j �I
department.,„',,,, .-� r r •, ,t(PRINT•OR-TYPE,ONLY) - _ _ - --•
/17G1 . . LOCALITY -
-bate� r �' 'Applicant' LI NO TYPE OF APPLIANCE OR•EOUIPMENT FEE
NEAREST,--
CERTIFICATE-OF EXEMPTION FROM WORKERS' CROSS ST 1 Y
COMPENSATION INSURANCE ABSORPTION UNIT,.BTU
This section need not be,com completed if the work•involved b 'the: ASSESSOR '
P P ( -, ) y AIR HANDLING UNIT;CFM s a 80oK. PROCESSED sseD civ, PARCEL r'
permit is for,one hundred dollars $100)or,
J,
l4certify that in the performance of the work-for which this permit
is^issued; 1-shall not employ,ariy person,in any manner so'as.,to BOILER,BTU
become'subject to the,Workers`Compensation Laws
•,t.i'. COMPRESSOR,BTU rJ '
APPROVALS DATE INSPECTOR'S SIGNATURE
Date• "' Applicant - VENTILATION SYSTEM
-
NOTICE TO APPLICAT NIf,`,after•making''this Certificate of � _ ROUGH i
-'Exemption,you should become subtectto the Workers' Compensation EVAPORATIVE COOLER r
•rovisions of the Labor Code; you must forthwith comply with'such' FINAL'
P �;1�{'�!' KtIl
provislons:or this permit shall be,deemed revoked. FURNACE. FAU GRAVITY' s
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'6ivis16n 3-of the Business and 1 HEATER: :WALL
Professions Code,and my licen�s.e is-in full,'force and effect-'
License'Numberl��� Y Lic Clsissl!%
Contractor '0 i C;L-*-
9_0
an check fee U
.�•- I am exempbunder Sec, Pl ;
B&P C.for reason' PERMIT ISSUING FEE $ O
Date, TOTAL FEE_ U
W
Signature "d
- PLAN CHECK APPLICANT
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 g,
.Code) ,-• - '. a ,. ADDRESS-,•. - t� .-. . .,• .5,.-1 ACCT'o Y'
" I,'as owner,of aha property, or my employees with wages �^ __
as their sole compensation,-will do the work and the CITY, i. TEL NO. "J 7 /' a' 307 ,, (■lir
'structure isnot intended;or'offered for sale (Section'7044; 1�_
Business and Professions Code)'- OWNER i JTEt11.1
�Y.
I, as owner ot,fhe property, ain exclusively contracting T '''
1 V 1 C?
MAIL A� d -�9a_v,
with licensed,eontradtors.to construct the protect (Sec- ADDRESS-
'tion 7044, Business and Professions Code) C,
HE0,, rr?;,�_�
CITY TEL-'NO'.
CONSTRUCTION LENDING AGENCY
- .,,r�`'`
''• hereby reby affirmtHAk
,that'there'is a construction lending agency for ! E ' •I�]
I
performance of the work for•which this permit is'issued CONTRACTOR
(Sec. 3097,Civ C.)
ADDRESS %) (+•'..� % �! JV } r
VOW-000
Lender's Name V V 1� 11/2019"'
CITY /. .. TEL NO.'.[j(! iC3J� ` s
Lender's Address 7 J M` G�7 6619- 1 AM 10:�J�
STATE LIC �.
I c"ertrfy.that I have read this application and state that the above LICENSE NO. ',(J CLASS C��a Cs3III Cp
information is correct. I agree to comply with all County ordinances
and State laws,relating to building construction,and hereby authorize'
representatives of his County to enter upon the above-mentioned ' LL
property for Ins cti purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
I TU E OF LICAN O NT ..l-DATE " •, - -