HomeMy Public PortalAbout4829 CAMELLIA AVE_Mechanical__ ryWORKER'S COMPENSATION DECLARATION 26A3640-0046 DPW
PW 9189 APPLICATION FOR PERMIT L���� �����
I'hereby affirm that have a certificate of consent to-self insure,'
or,a certificate of Worker's Compensation Insurance, or a certified tHEATING-VENTILATING -AIR CONDITIONING
copy thereof(Sec. 3800 Lab.'C.) -
P❑ollcy 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 building inspection FOR APPLICANT TO FILL IN ADDRESS
^ department. _ (PRINT OR TYPE ONLY) '
,LOCALITY
-Date Applicant - - .
NO. TYPE OF APPLIANCE OR EQUIPMENT, .FEE'
CERTIFICATE OF EXEMPTION FROM WORKERS" NEAREST, C
. CROSS ST. d G r �.C15 C,
COMPENSATION INSURANCE
ABSORPTION UNIT;STU ASSESSOR -
(This sectionneed not be completed if the work involved by.the - MAP BOOK PAGE _ PARCEL ,
permit is.for one huncred dollars($100)or less:) ^AIR HANDLING UNIT,CFM -
DISTRICTNO. PROCESSED BY
certify that in the performance of thework for which.this permit
is issued, I shall not ¢mploy'any person in any manner so as to BOILER,BTU - p
become subject to the Workers'Compensation Laws.
/ COMPRESSOR,BTU V4017 3 �"
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM _
NOTICE TO APPLICANT: If, after making this Certificate of _ ROUGH -
Exemption, you should become subject to the Workers' Compensation EVAPORATIVE.COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL.
provisions or thispermit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATIONS ^
I hereby affirm that•1 am licensed under provisions of Chapter 9. SUSPENDED UNIT_' -
(commencing with Section 70p0) of Division 3 of the Business and HEATER: WALL
'Professions Code, and my license is in full farce and effect. i
License Number Liu Class
D a
Contractor Date _ O
U
ElI amPlan check fee�exempt under Sec. -
B.&RC.for this reason - PERMITISSUINGFEE$ /{ 75 '- -; O
Date: TOTAL.FEE�r Q� .', .. �•'�.�._kl W
Signature - •1,. - { 1. :a 3 EL
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT - �,., _ Z
`�
I hereby affirm that I.am exempt from the Contractor's License Law NAME 1
for the following reason (Sectiom7031.5, Business and'Professions / i!_
Code)' ADDRESS •�./yfQ III � r
I, as owner of the property, ormy employees with wages
as their sole•compensation, Will do the work and the. CITY G /
structure is not intended or offered for sale (Section-7044, _- -
Business and Professions Code).• OWNER r , " r'
❑; ) O 6 re .vr.v of o f r y... ,11301 11'r 1,y y1
I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESSS((
tion 7044, Business and Professions Code).
.. CITY.. ^ TEI,NO.
' CONSTRUCTION LENDING AGENCY '1. - -
hereby affirm.that there is a construction-lend Ing agency for CONTRACTOR
he performance of the work for which this permit Is issued - - -
(Sec.3097,.Civ.C.).
. - ADDRESS
Lender's Name'
CITY TEL.NO`
Lender's Address STATE -LIC. - S
I certify that I have readthis application and state that the above LICENSE NO. CLASS r
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize - -
repFesentatives of this County to enter upon the above-mentioned -
`proper for inspectw Noses. SEE REVERSE FOR EXPLANATORY LANGUAGE
e ATURE OF APPLICANT OR AGEM ' X DATE -