HomeMy Public PortalAbout5725 CLOVERLY AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 200046 DPW 9/89 APPLICATION FOR PERMIT LIME GREEN'
76A364C '
I hereby affirm that I have a certificate of consent to self Insure
or aicertdicate of Worker s Compensation Insurance or a certified
HEATING=VENTILATING -AIR CONDITIONING '
copy thereof(Sec 3800 Lab C) -
Poli �
cy No � Company 5:JAJ6- FIti►�� COUNTY OF LOS ANGELES ,' ADEPT OF PUBLIC WORKS BUILDING'AND SAFETY DIV
Certified copy is hereby furnished ,
BUILDING
❑ Certified copy is filed with the county budding Inspection y FOR APPLICANT TO FILL IN ADDRESS
de artment (PRINT OR TYPE ONLY)
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Date, Apphcarit NO TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
CERTIFICATE OF EXEMPTIO FROM WORKERS NEAREST
COMPENSATION INSURANCE CROSS ST
T
ABSORPTION UNIT BTU ASSESSOR rT '
(This section need not be completed If the work Involved by the MAP BOOK 6 7 PAGE el Q PARCELoe.-;�' j
permit Is for one hundred dollars($100)or less) ` AIR HANDLING UNIT CFM DISTRICT NO PROCESSED BY t
I certify that in the performance of the work for which this permit
Issued, I shall not employ any person in manner so as to BOILER BTU
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become subject to the Workers Compensation Laws'
COMPRESSOR BTU /
_ APPROVALS DATE_ INSPECTOR S SIGNATURE
Date " ApplicantVENTILATION SYSTEM _ v
NOTICE TO APPLICANT If after making this Certificate of ROUGH
Exemption you should,become subject to the Workers Compensation -
EVAPORATIVE COOLER
provisions of the Labor Code you must forthwith comply with such + - FINAL
provisions or this permit shall be deemed revoked ' J FURNACE FAU GRAVITY t ^
LICENSED CONTRACTORS DECLARATION / FLOOR BTU O-DOG O - VALIDAT ON
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER - SUSPENDED t UNIT _
(commencing with Section 7000) of Division 3 of the Business and WALL - F
Professions Code and my license is in'full force and effect 4 r'
License Number' ' �Lic Class
Contractor L'+-T e/AL NAeT�ate V_ ;6 } "'"ACCT > _ C�U
I am exempt under Sec Plan check fee _ 33,37 Ilh.c: IM
B&P C for this reason PERMIT ISSUING FEE$ �� i ITEN'3
" Date
TOTAL FEE p� -7TOTAL�TAL 10m5 W
Signature T C HE1015 `` n'
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PLAN CHECK APPLICANT F H ° '
OWNER'BUILDER DECLARATION t
r N�E e I jtj z
I hereby affirm that I am exempt from the Contractors License Law NAME
for the followirig reason (Section 7031 5 Business and Professions
Code) _ > 4
❑ r ADDRESS r ,
-1 as owner of the property or my employees with wages t0000-000 1 4I 6/5-'
as their`sole compensation'will do the work and the CITY -TEL NO ' is 7
structure Is not Intended or offered for sale (Section 7044, 90�t 71 1 tAM
MID 12
Business and Professions Code) Z<NER ,> f v
❑ I as owner of the property am exclusively contracting MAIL y
with licensed contractors,to construct the project (Sec ADDRESS
tion'7044 rBusiness and Professions Code) -
CONSTRUCTION LENDING AGENCY CITY TEL NO3�)Yg 6 n
I hereby affirm that there-is a construction lending agency for
the performance of the work for which this permit Is issued ONTRACTOR
L9am• � ��7� ' 'v
Y ;
(Sec 3097 Civ C) T 4
ADDRESS
,Lender s Name "
CITY NI TEL NO
0(
Lender s Address STATE p LIC
I certify that I have read this application and state that the above LICENSE NO &7 7CLASS
Information Is correct I agree to comply with all County ordinances
and State laws relating to budding construction,and hereby authorize '
representatives of this County to,enter_upon the above mentioned ,
property for Inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGN URE OF APPLICANT OR OPENT DATE ` '