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HomeMy Public PortalAbout4926 CLOVERLY AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT I hereby affirm that 1 have a certificate of consent to self i;suLe, or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING or a certified copy thereof (Sec. 3800, Lab. C.) 76A364C 20-0046 DPW 9/88 Policy No. Company I Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY ❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING Tion department. ADDRESS (PRINT OR TYPE ONLY) Date Applicant LOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE � CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST p(,��// �� (This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. P CESSED BY the permit is for one hundred dollars ($100) or less.) D I certify that in the performance of the work for which this mAIR HANDLING UNIT, CFM permit is issued, I shall not eploy an Pers in any manner so as to become subject to the ns 'o aw BOILER, BTU APPROVALS DATE INSPECTOR'S SIGNATURE Dat Pl COMPRESSOR, BTU ROUGH NOT T-VAPPLI AN after mal�ng this Certificate of VENTILATION SYSTEM FINAL Exe ption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER ' 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: SUSPENDED UNIT_ S/ (commencing with Section 7000)of Division 3 of the Business WALL. and Professions Code,and my license is in full force and effect. a License Number Lic. Class , O V Contractor Date 09 ❑ O I am exempt under Sec. Plan check fee Q W B.&P.C. for this reason. H Date: PERMIT ISSUING FEE $ �� Z Signature TOTAL FEE d OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor's License , Law for the following reason (Section 7031.5, Business and NAME Professions Code): u I, as owner of the property, or my employees with ADDRESS ACCT. 0 a 4 wages as their sole compensation, will do the work and CITY • TEL. NO. the structure is not.intended or offered for sale(Section 33307 1,�,� ❑ 7044, Business and Professions Code). I, as owner of the property, am exclusively contracting OWNER 1 ITEMS . with licensed contractors to construct the project (Sec- MAIL - - 1-2.25 tion 7044, Business and Professions Code). ADDRESS TOTAL CONSTRUCTION LENDING AGENCY ._ CITY TEL. NO. ^� �-` iiO6,t I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued CONTRACTOR , CHANGE ,loll (Sec. 3097, Civ. C.). ADDRESS Lender's Name �!{� �-, p CITY TEL. NO. QOG�J-0001 9/19/8^ f 19/8 . Lender's Address c-� n I certifythat I have read this application and state that the STATE LIC. •.r 9 1 AM11.11 PP LICENSE NO. CLASS above 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 upeilyhe ab o entio d roper for inspe ton pur oses. SEE REVERSE FOR EXPLANATORY LANGUAGE ignature ppli ant or Agentto ©s