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Home My Public Portal About4812 CLOVERLY AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers' Compensation Insurance, EATING - VENTILATING�- AIR�COND�ITIONI� or a certified copy thereof (Sec.-3800,-tab. C-) 76A364C X20-0046 DPW 9/88 Policy No. Compaf,iy COUNTY OF LOS ANGELES BUILDING AND SAFETY ❑ .Certified copy is hereby furnished. F1Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING QQ�� •� tion departmen (PRINT OR TYPE ONLY)t. ADDRESS �l� 2 rLa L .. Date Applicant LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. f(0 Jg,ZiJ (This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCES eY the permit is for one hundred dollars ($100) or less.) (� I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM t� d permit is issued, I shall not em ya pers manner so as to become subject to The er Compens, 1 n Laws. BOILER, BTU APPROVALS DATE INSPECTOR' IGNATURE Date 74pplicant COMPRESSOR, BTU b ROUGH NOTICE TO APPLICANT: If, after making this Certi/\=rs of VENTILATION SYSTEM FINAL Exemptioh, .you should become subject to the Compensation provisions of the Labor Code, you m, h- EVAPORATIVE COOLER V TION with comply with such provisions or this permit shall be deem- ed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: USPENDE!5 UNIT_ OA -0 (commencing with Section 7000)of Division 3 of the Business �j and Professions Code,and my license is in full force and effect. d License Number Lic. Class // /'1� , O IQ L J V Contractor Date 0 ❑ I am exempt under Sec. Plan check fee ... B.&P.C. for this reason. d PERMIT ISSUING FEE $ Date: ? Signature TOTAL FEE OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor's License c , Law for the following reason (Section 7031.5, Business and NAME G Pr essions Code): � ADDRESS / LvY L /� , I, as owner of the property, or my employees with V � - wages as their sole compensation, will do the work and T iii C 1 n a the structure is not intended or offered for sale(Section CITY I TEL. NO. 7(j 6 7044, Business and Professions Code). -tom`if ��'al_iI ❑ OWNER - I, as owner of the property, am exclusively contracting 1 ITENG with licensed contractors to construct the project (Sec- MAIL tion 7044, Business and Professions Code). ADDRESS TOTAL 93m00 CONSTRUCTION LENDING AGENCY CITY TEL. NO. I hereby affirm that there is a construction lending agency for CHECK 913°(_ll,; CHECK the performance of the work for which this permit is issued CONTRACTOR , � .011 C ht (Sec. 3097, Civ. C.). ' �� ADDRESS Lender's Name �y E CITY TEL. NO. l 000-0001 ,.:// 2iri190 Lender's Address I certifythat I have read this application and state that the STATE CLASLIC. S ;;;[I PP LICENSE NO. CLASS above formation is correct. I agree to comply with all County ordina ces an tate laws relating to building construction; and h by a h ize presentatives of this County to enter upon t ov - io ed property for inspection urposes. ` SEE REVERSE FOR EXPLANATORY LANGUAGE Signature Applicant or gent Date ©1