HomeMy Public PortalAbout6037 CLOVERLY AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89 APPLICATION FOR PERMIT LIME GREEN
20-0076A364C
I hereby 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
copy thereof(Sec.3800 Lab. C.)
Policy 12-2I n"94-Company JTA1E Funk COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
R3 Certified copy is hereby furnished.
EJCertified copy is filed with the c my buil g spection FOR APPLICANT TO FILL IN BUILDING
department. (PRINT OR TYPE ONLY) ADDRESS J 4
Date &-ZS`9L Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT .FEE LOCALITY 1 e 'e C,4,,
_
CERTIFICATE OF EXEMPTIO FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST. ���
ABSORPTION UNIT,BTU ASSESSORr /
(This section need not be completed if the work involved by the MAP BOOK j PAGE4O(O PARCEL�16
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 O
become subject to the Workers' Compensation Laws. D
COMPRESSOR,BTU
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 `
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby all 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. b
Licenseu 0 Lic.Class
, CL
Contractor er ,r.aS-9L 0
Date Com} 0
EJ Plan check fee
I am exempt under Sec. A
PERMIT ISSUING FEE $ AUT. O
,r
-BAP.C.for this reason 3303 80.50 V
Date: TOTAL FEE Q U 1 ITEI'I W
a.
Signature PLAN CHECK APPLICANTI_I>a AL � � V)
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law NAME , CHECK 80.50
for the following reason (Section 7031.5, Business and Professions e GLr��'LS
Code): ADDRESS �O3 D, - 9Th A,c CHANGE .00
❑ I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY rtc- TEL.NO. y(4J _Z®�(O
structure is.not intended or offered for sale Section 7044, b �10 {}'r 4q
Business and Professions Code): ( OWNER �^ i �e �� S t.SrJ�Q�V)JI)1 ����i1��
❑ I, as owner of the property, am exclusively contracting MAIL 7107 1 PM 1 45
with licensed contractors to construct the project (Sec- ADDRESS GOI-) C�OVCA
tion 7044, Business and Professions Code). `�
CONSTRUCTION LENDING AGENCY CITY Y 2 �, TEL.NO.
Thereby affirm that there is a construction lending agency for OT
CONTRACTOR ��"' 01110.
(Secperformance of the work for which this permit Is issued c� f constfuC-Tvf3
(Sec.3097, Civ. C.).
ADDRESS 303 S 4�
Lender's Name
CITY q TEL.NO. LftJb-Ld(e0
Lender's Address
I certify that I have read this application and state that the above LICE SE NO. 1mS7S d0 LI
13
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
presentotves' of this County to enter upon the above-mentioned
party action purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
S-9�LICANT OR AGENT DATE