HomeMy Public PortalAbout5649 CAMBURY AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 20�16DPW 9/89
76A364APPLICATION FOR PERfVIIT �� � �����- , ,
78A364C
I hereby affirm that I have a certificate's of consent to self insure,
ora certificate gf Worker's Compensation.Insurance, or a certified " II<1G HEAT -VENTILATING-AIR�CONDITIONIN•G
copy rKereof(Sec.J, Lab.C.)
PolicyN . 7�¢L6q Company .S! FC m �7 C ..
� � COUNTY OF LOS ANGELES A
DEPT PUBLIC WORKS BUILDING AND SAFETY DIV:
Certified copy is hereby furnished.
❑ Certified co Is filed with the count build ing Inspection FOR APPLICANT TO FILL IN BUILDING
copy Y 9 (PRINT TYPE ONLY) ADDRESS
Ail 04 hi a 44R V
department_ - . . /J - ( -
.Date 57 / �'. S Applicant fly- 7-5_ Q.,GC, - - LOCALITYGrl PL /g
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS'- NEAREST ,n - -
COMPENSATION INSURANCE CROSS ST. 0/9_
ABSORPTION.UNIT,BTU ASSESSOR
(This section,need not be completed if the work involved byy-the - MAP BOOK -PAGE PARCEL
permit is for One hundred.dollars(5100)or less.) 'AIR HANDLING UNIT,CFM
olsTalcT NO aaocsss r
I certify that in the performance of the work for which this permit
is issued, shall not employ any person in any manner so as to BOILER:BTU _ t
become subject tothe Workers'Compensation Laws: - —x � )`- • 4
'• ' _ •� COMPRESSOR,BTU r90. tl O U `
Dale Applicant - - VENTILATION SYSTEM :APPROVALS " DATE wsva oR's SIGNATURE
NOTICE'Td APPLICANT: If, after making this Certificate of ROUGH,
Exemption, you should-become subject t6 the Workers'Compensation EVAPORATIVE COOLER v
provisions of theLabor Code, you must forthwith comply,with suchF INAL •- "a. y\h_ ..
provisions or this permit shall be deemed revoked.^ FURNACE: FAUGRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR 'BTU U! 'g -,UATION' �
_I hereby affirm that I am licensed-under'provisions of Chapter'9 - SUSPENDED UNIT_
HEATER: - 2.
(commeons with Section icons of Division 3 of the Business and WALL . . ^ff. -
-Professions Code and`my license is in full force and effect.
3 3 2 3 Lic.Class Cz . t,.,�
License Number vin {6��- (/
Contractor �/ `� 6441'Date '5—/S,,- (p• FAu r..a.r� V.eaJ G D '�I 0
-
am exempt under Sec. Plan check fee V_ '�� _cc
B,BP.C.for this reason '. PERMIT ISSUING FEE$ 2-7 F—
Dale: TOTAL FEE 60 50 at - - W
Signature - d
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT - Z
.. . .. '{ " .I n
I hereby affirm that I am exempt from the Contractor's_License Law, � NAME.
for the following reason (Section 703t:5,•B bsiness and Professions
Code): ADDRESS -
❑ L'as owner of the•property; or my employees with wages - ACCT..AT ,
'will do the work and the i �
as:their sole.compensation, CITY TEL NO: JOOJ; -80.50
structure is not intended or offered for sale (Section 7044, JO Ku
Business and Professions Cade). - - - OWNER ` -IffR ; b .1 ITERS'
.� i, as owner of the property, am exclusively contracting _MAIL ,'rt -
with.licensed contractors to construct the project (Sec- DDRESS S6 TT.OTAL 4330,_.50
'tion 7044, Business and Profession s-0ode). - ' CITY T TEL.NO. {' �+ �/ _ 'CHECK v�.1C
`• CONSTRUCTION'LENDING AGENCY / I�YI P[ G I .��6/ b /. etc n'
I'hereby affirm that there is a construction lending agency for - �O A �O - - V CHANGE i ..0V
the performance of the work for which this permit Is issued CONTRACTOR Jl .
(Sec.3097. Civ:C.). , / . . T Df ;.' .w s '
(Be
ADDRESS �14 R ¢C • - - <
Lender's Name 0000-0001. .,5!15[96'.
CI ( C-G L_M v9 TEL. 6421 1 All 9:24
LenderAddress STATE 3 7 �7 3 CLC
LASS C Q C3 ,
I certifythat I have read this application.and state that.the above LICENSE NO. J OC
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 dor inspection pur oses SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APPLICANT OR AGENT DATE - ,