HomeMy Public PortalAbout5453 CLOVERLY AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 46 DPW 9/69 APPLICATION FOR PERMIT LIME GREEN
76A3
w I hereby affirm that I have a certificate of consent to self insure, 76A364C
or a certificate of Worker's Compensation Insurance, or a certified HEATING -VENTILATING -AIR CONDITIONING
copy thereof(Sec.3800 Lab. C.)
Policy No. ompany SI 14 I M Q COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN BUILDING ��
Certified copy is filed with the wilding inspecti�q ADDRESS
rtent. ( _� (PRINT OR TYPE ONLY)
Date
,7/-m,���APPlicant ?V I Z LOCALITY CITY ,
' I T v
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE l•
NEAREST
Gii GA e 11!1
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST.
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 �r
become subject to the Workers' Compensation Laws. /
COMPRESSOR,BTU fyZB'OTJ oZ
' 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 STI
provisions or this permit shall be deemed revoked. / FURNACE: FAU GRAVITY s— VALIDATION
LICENSED CONTRACTORS DECLARATION FLOOR BTU
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.
License Number Lic.ClassPT
fit':3 a 9 O
Contractor Date
El I am exempt under Sec.
Plan check fee '�)
B.&P.C.for this reason PERMIT ISSUING FEE
$ ' �` `
TOTAL AL 109 a 55 v
Date: TOTAL FEE
Signature -.HECK -.° ; �
OWNER-BUILDER DECLARATION C.PLAN CHECK APPLICAN -.HECKNN i�iE °j{!J z
I hereby affirm that I am exempt from the Contractor's License Law NAME Poo
the following reason (Section 7031.5, Business and Professionstt� i a
Code): ADDRESS
❑ I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL.NO. its3 fly Ian_'
structure is not intended or offered for sale (Section 7044,
Business and Professions Code). OWNER t1l R /2 7V4011/
I, as owner of the property, am exclusively contracting MAILv [
with licensed contractors to construct the project (Sec- ADDRESS 3`15-3C LO U` 0,LI S1 _
tion
1-
tion 7044, Business and Professions Code). n
CONSTRUCTION LENDING AGENCY CITY ��ly TEL.NO. 7 �j
1 hereby affirm that there is a construction lending agency for CONTRACTOR � �+ oA ` vv,
the performance of the work for which this permit Is issued11 U
(Sec.3097,Civ.C.).
ADDRESS C1� b F�LC
Lender's Name
CITY P .2 TEL.NO
Lender's AddressLIC.
STATE ^�L
I certify that I have read this application and state that the above LICENSE NO. � 0 1 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 e r u on the above-mentioned
proper inspec'on purp.9spis. SEE REVERSE FOR EXPLANATORY LANGUAGE
7- ?L
SIGNATURE OF APPLICANT OR AGENT DATE