HomeMy Public PortalAbout9033 CALLITA ST_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/69 APPLICATION FOR PERMIT .����,., �����'
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I hereby�afh�yn that I have a certificate of consent to self insure
or a-certihc5to o);worker s'compensation Insurance, or a certified -HEATING -VENTILATING -AIR CONDITIONING -
cap
.y thereof(See.3800 Lab C.) �j = - - •. - -,—
Policy No.x4,12' 41 Company=�•�/t�%�e /`"t�� ,. COUNTY-OF LOS ANGELES - •r DEPT OF-PUBLIC WORKS BUILDING AND SAFETY DIV._
-❑' " .-.Certified copy is hereby fu rnis had. /�� - - '•
BUILDING p --
❑ Certified cepyiis4iled with theBooty 1111 - -, -FOR'APPCICANT TO-FILL IADDRESS
de Arm_igt. - - (PRINT OR TYPE ONLY)
Date Z APPlicant - - , LOCALITY- '
NO. - TYPE OF APPLIANCE OR EQUIPMENT FEE' + -
�r C RTIFICATE OF EXEMPTION jrROM WORKERS' CROSSSST:.
' COMPENSATION.INSURANCE - ABSORPTION UNIT;BTU
(This section need notbe cam letetl if the work involved b the ASSESSOR p^ '
( P Y ,� �'yy MAP BOOK �p:�` PAGE.O// PARCEL'Qa3
permit is for one hundred dollars($100).o less.)- AIR HANDLING UNIT,CF v DISTMU No. sem- Pnocssseo BY
I certify that in the;performance of the work for which this permlf;
is issued, ishall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers' Compensation Laws - • - '�QG .�iLLv�-��,�J
- COMPRESSOR,BTU booO So '
OnTe insPEc.oR's sicnamnE,APPROvs
Dale Applicant VENTILATION ATION SYSTEM %+
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH /
Exemption,you should become.subject to'the,Workers Compensation EVAPORATIVE COOLER ` -
provisions of the Labor,Code„you must forthwith comply.with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: b FAU GRAVITY
- LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION.
I hereby affirm thatI am licensed•under provisl0ns'of Chapter 9 SUSPENDED UNIT_. -
(commencing with Section 7000)of Division'3 of the$u siness and HEATER: WALL
. Professions Codepand my Ilceose is in full force and;bffect. 0 50010t1v
License Number &3004ffq Lie.Class Z 4M” Ate 7l7E'1 -
' 1.
Contrac Dated gy - -- - -
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exempt under Plan.check.feecc
. ._
a Sec cc
B.BP.C.for this reason _ PERMIT ISSUING'.FEE $ q O,
Date: TOTAL FEE W
Signature' -
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OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT - - , ,(n
Z
I hereby affirm that I am exempt from the Contractor's License Law NAME to
forthefollowing reason (Section 7031.5, Business and Professions
) d
�e'
• ADDRESS V `
I, as owner otthe,property, or my employees with,wages t
ACG .
_ as their sole compensation, will do the wor k'end the CITU 'TEL NO.
structure is not intended'or offered for sale (Section 7044, 07 10:+L71
Business and Professions Code) OWNER TQQ C�! ,
.❑ I, as owner of the.property,,-am exclusively contracting MAIL 4 EIIJ
i IT
_with licensed contractors to construct the project (sec- ADDRESS D3-. 6' ua7-4 -` . ,:TOTAL 16:3 .71.
tion 7044, Business and Professions Code). - - >,1 , /'�Lt /�/
CONSTRUCTION LENDING AGENCY CITY err`_ ."TEL.NO.'a S:j �Cfls'L " - 4tlEbr�'.•,,;. .153•'1
hereby'affirm that there is a construction lending agency for - 'CONTRACTOR trftllAb ,III
the•;performance of the work for which this permit is issued CHANUE
(Sec:3097, Civ.C.). -s',:"
ADDRESS�Y N• /L, ✓r•'xY ,.q fr r1_ /
Lender's Name CITY w,i / TELL r ,G,Z �. - "y�w VV�t`.• V�31/'9e.
CLiLI. ' 341=M
Lender's.Address _ 5142.. hI 0"53
STATE {o3B2 -''C ASS B _ -.1 iTAM:V•v.� -
certify that have read this application and slate that.the above LICENSE NO. 1f� . .
information is correct. I agree to comply with all County ordinancesand State laws relating to building construction,and hereby authorise -' "*,GR
ofthis C my to enter upon the above-mentioned pectiorposesSEE REVERSE FOR EXPLANATORY LANGUAGE
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