HomeMy Public PortalAbout5414 CLOVERLY AVE_Mechanical__ WORKER S COMPENSATION DECLARATION 20 0046 DPW 9/89
76A364C APPLICATION FOR PERMIT LIME GREEN ,
76A364
I hereby affirm that I have a certificate of consent to self Insure
or atertificale of Worker s Compensat on Insurance or a certified. HEATING-VENTILWANG -AIR CONDITIONING
copy thereof(Sec 3800 Lab ) i
Polic -ompany J 1 COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
Certified copy is hereby fumished
❑ Certified copy is filed with the county building Inspection FOR APPLICANT TO FILL IN BUILDING
ADDRESS
Wart M.
i `� (PRINT OR TYPE ONLY)
Date l �G A licant ��� LOCALITY,
PP NO'` TYPE OF APPLIANCE OR EQUIPMENT , FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST + J
' COMPENSATION INSURANCE �'
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
become subject to the Workers Compensation Laws (_
COMPRESSOR BTU tl� O ��
i APPROVALS , DATE INSPECTOR SSIGNATURE ,
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 G VI VALIDATION
LICENSED CONTRACTORS DECLARATION FLOOR BTU
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 ��
1T_ s x/
License Number Lic Class J" fy 4
3 ACCT.4 ;a
Contractor _ Date f1 t 0
❑ I am exempt under Sec Plan Check fee ,�OOJ 110 a Q
B 8P C for this reason PERMIT ISSUING FEE 1 ITEMS, OO
Date TOTAL FEE TOTAL 116 - 55,o
LLJ
f Signature r CHECK 116e55 _�
{ PLAN CHECK APPLICANT
OWNER BUILDER,DECLARATION CHANGE e00 Z
I hereby affirm that I am exempt from the Contractors License Law NAME ( O
for the following reason (Section 7031 5 Business and Professions r
Code) I ADDRESS S l
❑ I as owner of the property,or my employees with wages 111 OWO-0001 - 7/15/96- 1-
as their sole compensation'will bo the work and the CITY TEL NO, (� 7435 � 1 AM11:2j ,
structure Is not Intended or offered for sale (Section 7044 -
Business and Professions Code) OWNER
1 as owner of the property am exclusively contracting MAIL
with licensed contractors to construct,the project,(Sec ADDRESS 4
tion 7044 Business and Professions Code) CITY TEL NO
CONSTRUCTION LENDING AGENCY }
hePby affirm that there is a construction lendagency for or CONTRACTOR' 4
the erformance of the work for which this ermit is issued AA�_ ,{�
(Sec 3097 Civ C)
• + ADDRESS
Lender s Name, CITY ,•v TEL NO 3 S } r +
Lenders Address �f,
I certify that I have read this apphcation and state that the above LICENSE NO ` 2 LIC
Information is correct I agree to comply with all County,ordinances _
and State laws relating to budding construction and hereby authonze
representatives of this County to enter upon th above entioned
pro-Arty for spectio ur ses SEE REVERSE FOR EXPLANATORY LANGUAGE
II
SIGNSIGN E O A P O AGENT DAT ,