HomeMy Public PortalAbout4841 CLOVERLY AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 46DPW 9/89 APPLICATION FOR PERMIT LI E GREEN
I hereby arm'that I 76A3
have a certificate of consent to self insure, 76A364C
or a certificate of Worker's Compensation Insurance, or a certified J HEATING-VENTILATING -AIR CONDITIONING
copy thereof(Sec. 3800 Lab.C.) u
Policy 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 BUILDING
ADDRESS �, G
department. (PRINT OR TYPE ONLY)
DateApplicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
(This section need not be completed if the work involved by the ASSESSOR
permit is for one hundred dollars($100)or less.) MAP BOOK � PAGE DB PARCEL��
AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers' Compensation Laws.
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL
Professions Code, and my license is in full force and effect.
V
License Number Lic.Class ACGT ILa
IL
Contractor - Date 3303 31 a r0
❑ Plan check fee 1 ITEMS
I .& exempt under Sec. 3Q TOTAL 3 �._ 50 5
B.&P.C.for this reason cc
PERMIT ISSUING FEE$
Date: TOTAL FEE / lj CHECK31.50 W
Signature CHANGE .00 a
PLAN CHECK APPLICANT 0 CO
OWNER-BUILDER DECLARATION nn0--0001 1� o 4��rh Z
I hereby affirm that I am exempt from the Contractor's License Law NAME 000
'
for the following reason (Section 7031.5, Business and Professions
I, as owner of the property, or my employees with wages ADDRESS 4097e
1 AM11;02
as their sole compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale (Section 7044,
Business and Professions Code). OWNER
❑ I, as owner of the property, am exclusively contracting MAIL
with licensed contractors.to construct the project (Sec- ADDRESS ,
tion 7044, Business and Professions Code). /
TEL.NO
CONSTRUCTION LENDING AGENCY CITY l• OG�
I hereby affirm that there is a construction lending agency for CONTRACTOR ,
the 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:
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
er inspection oses. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIG F APPLICANT OR AGENT DATE