HomeMy Public PortalAbout9925 BOGUE ST_Mechanical__ WORKER'S COMPENSATION DECLARATION 46DPW 9/69
76A364C APPLICATION FOR PERMIT. LIME GREEN;
I hereby affirmlhat I have a certificate of consent to self insure, 76A3
or a certificate of Worker's Compensation Insurance, or a certified 'HEATING-VENTILATING-AIR CONDITIONING,
copy thereof(Sec.3800 Lab.C.) u
Policy No. Company COUNTY OF LOS•ANGELES DEPT.OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the county buildingInspection FOR:APPLICANT TO FILL IN. BUDDING �j
department. (PRINT OR TYPE ONLY)' ADDRESS Y Z
Date Applicant LOCALITY
PP NO. TYPE OF APPLIANCE OR EQUIPMENT F,EE
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
This section need.not be completed if the work involved b ASSESSOR
( Y the P MAP BOOK • PAGE .PARCEL '
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
certify that in the performance,of the work for which this permit -y
is issued, I shall not employ any person in any mannei so as to BOILER,BTU y
become subject to the Workers' Compensation Laws. l �O c LLtt G�C�a
_ l/I!✓\ / COMPRESSOR,BTU a o o
APPROVALS' DATE INSPECTOR'S SIGNATURE
Date R ' Applicant VENTILATION SYSTEM-
, NOTICE TO APPLICANT: If, after making t is Certifi of ROUGH
Exemption,you should become subject to the or ers' Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forth comply with such FINAL _
provisions or this permit shall be deemed revoked. / FURNACE: FAUGRAVITY VALIDATION
LICENSED CONTRACTORS DECLARATION / FLOOR BTU'
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT '
(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect.
License Number Srv� Z Lic.Class 2 0
C� /�C�. rue — LI — �- , O
Contractor Date
❑ Plan check fee
I am exempt under Sec. �
B.&P.C.for this reason PERMIT ISSUING FEE$ Lf ,V
Date: TOTAL FEEa
Signature CO
PLAN CHECK APPLICANT
OWNER-BUILDER DECLARATION Z
I hereby affirm that I am exempt from the Contractor's License Law NAME7 ,
for the following reason (Section 7031,5, Business and Professions S �°� �� ' /A)
Code): ADDRESS �z_e
❑ I, as owner of the property, or my employees with wages ACCT°T
as their,sole compensation, will do the work and the CITY 9 TEL.NO. c, c
structure is not intended or offered for sale (Section 7044, �f +� 3307 71.*
Business and Professions Code). OWNER LJ I TT�ptM
❑ I, as owner of the property, am exclusively contracting / . S I 11 '
25
with licensed contractors to construct the project (Sec- ADDRESS �.�^ 1j c C�Gd .S TOTAL 71
tion 7044, Business and Professions Code). q t'
CONSTRUCTION LENDING AGENCY CITY L� TEL
NO. Z,f 7 Z CHECK 7'i°�_t
I hereby affirm that there is a construction lending agency for CONTRACTOR 'e , rtlA`�C •.�.Il
the performance of the work for which this permit Is issued � '� /w c- 1:Tz!•'t!"�G
(Sec.3097, Civ.C.).
ADDRESS /n y rLy��2
Lender's"Name �f �cL c�e
��y� C� / f i
CITY TEL.NO. CI.7�•'�{.�F�1{:.�• ill�.St�+i
Lender's Address �^Y qqA�• ° J
STATE LIC. to . .C-yT• -�• °�'�
I certify that I have read this application and state that the above LICENSE NO. Z CLASS y
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
property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
C� � -til _ 2' •..
SIGNATURE O PLICANT OR AGEYJ DATE