HomeMy Public PortalAbout4927 CLOVERLY AVE_Mechanical__ .WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89 APPLICATION FOR PERMIT AIME GREEN:
� 76A364C
I her&Iy affirm that I have a certificate of consent to self insure, [�
or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING -AIR CONDITIONING I I
co thereof(Sec.3800 Lab. C.
Policy No. b�� Company � � u� COUNTY OF LOS ANGELES : DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
BUILDING
�. Certified copy is filed with the county but din inspection FOR APPLICANT TO!FILL IN ADDRESS 7 Y
department. �j N0. TYPE OF APPLIANCE OR EQUIPMENT FEE
(PRINT OR TYPE ONLY)
Dafp/(_1,)cpr 3-�`t.- `3 Applicant LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS ST.
COMPENSATION INSURANCE Z�JI.
ABSORPTION UNIT,BTU ASSESSOR
(This section need not be completed if the work Involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) 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 p
become subject to the Workers' Compensation Laws. 14 O
COMPRESSOR,BTU VO O
APPROVALS DATE INSPE R'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 ITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU 000 VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect.
License NumberILpio.Class •-
Contractor ate
ElPlan check fee
I am exempt under Sec. At T o T.. a:
BAP.C.for this reason PERMIT ISSUING FEE S 3307 113.381__a
Date: TOTAL FEE 1 I�'� a
Signature - ♦ --� C/)
PLAN CHECK APPLICANT TOTAL r .1 13..3v
OWNER-BUILDER DECLARATION t1 rl� Z
1 hereby affirm that I am exempt from the Contractor's License Law NAME , CHECK 11UedV
for the following reason (Section 7031.5, Business and Professions �I,�I'
Code): ADDRESS CHANGE
I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL.NO. r'
structure is not intended or offered for sale (Section 7044,
V000- 1 9/ iF.f ;.
Business and Professions Code). OWNER - t-T
❑ 1, as owner of the property, am exclusively contracting MAIL Y Tt� 0.N #�) 5367 1 --"10:0
with licensed'contractors to construct the project (Sec- ADDRESS I yL'Q l S Y
tion 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY C ® TEL.NO.4il't(f.2,
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 N at
Lender's Name /�� L
CITYCou I,")4 TEL.NO. v^t� t r
Lender's Address 5 0 G
STATE II LIC. /� � > �-1 ,
I certify that I have read this application and state that the above LICENSE NO. l � CLASS l.� pW
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
pro y for ins ectio9 purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
y 9 7-
S NA RE OFAPPLICANT OR AGENT J5ATE