HomeMy Public PortalAbout5353 BUTTONS AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9189 APPLICATION FORPERMIT,.76A364C GREEN"ftC�.,P�
-I hereby attire that I hav-. a Oepe sats of consent to o self insure, - ..-LIME . gg Lig �If'�f
ora certificate of Workeres' Compensation Insurance or a certified - HEATING -VENTILATING -AIR CONDITIONING @L117UIIL'SSS L7 ddd VVV
co thereof(Sec'.3800 Lab. C) •• -. "CO- ___ • _ . .. ,
`E`E`a34on �i C'mbYlt COfY1 CYl
ofcy No. Company V OF LOS ANGELES DEPT OF PUBLIC WORKS.- BUILDING AND SAFETY DIV.
'� Ceddled'copy is hereby furnished.: y t
❑ Codified copy is filed with the county.building inspection FOR-APPLICANT TO FILL IN" - BUILDINGLOCALITY
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T�de�ar�tm)ent�. ' (PRINT OR TYPE ONLY) _ ADDRESS i3
Date GJ-_LL—A'plicant - -
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE IC.
CERTIFICATE-OF EXEMPTION F M WORKERS' - NEAREST - -
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COMPENSATION INSURANCE_ - ___ ..•, „_ , _-. ABSORPTION UNIT,.BTU- -- = -- _._.
ry
CROSS ST �; _ ••' '.
This section need not be completed if the work involved b the. 'ASSESSOR — - - - -
( P Y' - ' MAP BOOK PAGE -y PARCEL -
permit is for one huntlred'dollars,($100)or"less.) AIR HANDLING UNIT,CFM
DISTRICT NO PROCESSED aY
I'•certify,that in the performance of the workforwhich this permit
is.issued, I shall not employ any parson in any manner so as to BOILER,RTU L' Y
become subject to the Workers' Compensation Laws.
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• - COMPRESSOR,BTU [7U O IO -
Date Applicant - VENTILATION SYSTEM ` -- AwaOvus Onre IrvsPEcr4 slGrvnTURE
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH Exemption,you should become-subject-to the Workers:Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL. a .
provisions or this permit shallbe deemed revoked. FURNACE:., FAU GRAVITY - _ -
LICENSED CONTRACTORS DECLARATION ' FLOOR - BTU �17 VALIDATION
(hereby affirm that I am licensed under provisions of Chapter 9 . .:SUSPENDED - UNIT_. t` -
(commencing with Section7000)of Division 3 Of the Business and HEATER: WALLProfessions Code,and y.license is in full force and effect. -
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License Number U� Lic.Class C"r�
tit-:T�s i
COntractorNES t4 ;w -CtjDate n--q-95 - - - '_ice. a
❑ �I am exempt under Sea Plan Check fee - r^` T i ti - 10 O
Q
B&P.C.for this reason ,PERMIT ISSUING FEE$ 2 'O
Et �" 1+
Date: _
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' .Signature
- OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT -
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I hereby affirm that I am exempt from the Contractor's License Law NAME C,JuU
for the followtng.reason (Section 7031.5, Business and Professions >,. - - ii^
Cade): - ADDRESS r04 .J,. _ hi ri Uf /4 .
I, as owner of the property, or.my employees with wages
as{heirsole compensation, will do the workand the CITY TEL NO.. -
structure'is not intended or offered for sale (Section 7044, - -
Business and Professions Code)..: OWNER ('
❑ 1, as.owner of the property, am exclusively_contracting
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with licensecontractors.to construct the project (Sec- ADDRESS 3 (•( rI1/e - _ ,
tion 7044,.Business and Professions Code). -
- CONSTRUCTION LENDING AGENCY CITY TEL.NO.' - 11
I.hereby affirm that there is a construction lending agency for CONTRACTOR -
r�the performance of the work.for which this permit Is issued •-
?(Sec.3097, Ci,C.)_ II_- �yv, C /�•�
- ADDRESSJ' V V. 1 1 f - .
Lender's Name
' � - CITY '. h TEL�NO.
Lender's Address - STATE V LIC. F.
I certify that I have read this application and state that the above LICENSE NO. - 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 'p pectian purposes. 1 SEE REVERSE FOR EXPLANATORY,LANGUAGE" l .�
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111DAD7 01APPLICall OR AGENT PATE � � "