HomeMy Public PortalAbout5922 BURTON AVE_Mechanical__ WpRKER'S COMPENSATION DECLARATION 1I20-0046 DPW 9le9, APPLICATION FOR PERMIT
I haffirm that I have a certificate of consent to self 76A364
insure, 76A364C � '
ora certificate,ot'Worker's Compensation Insurance, or a certified HEATING -VENTILATING -AIR CONDITIONING
copy thereof(Sec. 3800 Lat II .)
Policy No.I'll 0 p ny ;7{N l(� /✓f/
-ter COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished. ��"_j /� - '
Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING
department. p (" (PRINT OR TYPE ONLY) ADDRESS rj o
Date Applicant L!'7. 714 J LOCALITY
�• N TYPE OF APPLIANCE OR EQUIPMENT FEE
C RTI FI ATE OF EXEMPTION FROM WORKERS'J( NEARESTT.
COMPENSATION INSURANCE CROSSS
ABSORPTION UNIT,BTU' ASSESSOR
lop
(This oneetl not be completed if the work involved by the - MAP BOOK PAGE PARCEL
permitt is is for
one hundred dollars($700)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED By
1 certify thatin the performanceof the work for which this permit
is issued, I shall not employ any person in any manner-so as to 'BOILER,BTU p
become subject to the Workers' Compensation Laws, ^.(
i " • COMPRESSOR.BTU
/A/ O PPPROVALS DATE INSPECTOR'$SIGNANRE
Dale pplicanl - •/A/ VENTILATION SYSTEM
NOTICE'TO APPL ANT: If, aft making this Certi cats 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 -ZY
provisionsor this permit shall'be deemed revoked. FURNACE FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR 'BTU /r(F' b VALIDATION
hereby affirm that 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 yyb Lic.Class
/ D a
Contractor "Z, r/ Date - U
❑ I am exempt under Sec. Plan Chef(fee _
v
8.8P.C.for this reason _ PERMIT ISSUING FEE$ .p
Date: WXT.4 ~
TOTAL FEEW
U 3 -r
Signature - 3307 174.CL! n.
PLAN CHECK APPLICANT 2 C!�
I OWNER-BUILDER DECLARATION n1 ITEi'I_• c'1 Z
1 hereby affirm that I am exempt from the Contractor's License Law NAME D TOTAL
179 e 03,
for the following reason (Section 7031.5, Business and Professions Lr-
Cotle): ADDRESS: CHECK '179.11�.
❑ I, as owner of the property, or my employees with wages _
as their sola compensation, will do the work arid the CITY TEL.NO. _ CHAHGE .flit
structure is not intended or offered for sale'(Section 7044, -
Business and Professions Code). - OWNER nn
❑ i, as owner of the property, am exclusively contracting 'MAIL 9 04
- 0000-0001 4J��J]2
with licensed contractors to construct the prolecL,(Sec- ADDRESSZZ d - &J ,
. / : / LJ AM
f
IT L
tion 7044, Business and Professions Code). n. - " 5114 1 IRI 9:N
CONSTfl UCTION LENDING AGENCY - -0I.N TEL.NONO,:;?[gZ— 2
hereby affirm that there is a construction lending agency for -
the performance of the work for which this permit is issued CONTRACTOR �p p
7
(Sec. 3097.Civ. C.). . ,•Q/i,, /`J '�e D
ADDRESS tT C �fj Lq•C . .
Lender's Name
CITY I7 EL.NO.
Lender's Address !� ,/ 7/� [O _
I certify that I have read this application and state that the above 51 ETNSE NO. rJ 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 -
property'for n pectionSEE REVERSE FOR EXP p po s. - -
EXPLANATORY LANGUAGE
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SIGNATURE O P ANT OR AGENTV DATE ,