HomeMy Public PortalAbout6632 CLOVERLY AVE_Mechanical__ WOIAKER'S.COMPENSATION DECLARATION 20-0046
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I hereby affirm that I have a;certificate of consent to Bel f.insure, C. uVl u�u
or a certificate'of Worker's Compensation Insurance, or a certified
HEATING'-,VENTILATING AIR CONDITIONING LLL��� u�LLL���LLL���IIIJJJ IUUJ
copy thereof($ec.3600 Lab. C.),-
Policy No Company.' UNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND`SAFETY DIV.
❑ Certified copy is hereby furnishadE•,.
FOR APPLICANT TO.FILL IN BUDDING
Certified.eopy is flied with the county building inspection ADDRESS
., d artm t. (PRINT OR TYPE ONLY)
' LOCALITY
Dat Applicants NO: TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSSNEAREST.
CO4PENSATIONi1NSURANCE 'ABSORPTION UNIT;BTU'
(This section,need not,be,completed if the work involved by the ASSESSOR
ermit is.for:one hundred dollars($100 or-less. MAP BOOK PAGE PARCEL
p ) ) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY
1 certify th'at'in the performance,of the work fo,r:which this permit
Is'issue"d, I shall.not,'employ any person in any manner so as to. BOILER,BTU �D y
become subject torthe Workers' Compensation Laws. O
COMPRESSOR'BTU L APPROVALS' DATE INSPECTOR'S SIGNATURE
Date AppliC ,�G VENTILATION SYSTEM'
p y LICANT: 1f, after rrfaking.this Certificate of ROUGH
+NOTICE TO APPuId become.subject4o the Workers' Compensation EVAPORATIVE Exam tion, ou sho
provisions of the Labor Code, you must'forthwith comply,with such FINAL
provisions:or.this,permit shall tie deemed revoked. FURNACE FAU_ G V
LICENSED CONTRACTORS DECLARATION FLOOR BTU Cl VALIDATION
('hereby'-affirm that•'1 am'licersed under provisions of Chapter'9 SUSPENDED UNIT
(commencing with'.Section.7000) of�Division 3 of the Business and HEATER: yygLL
Professions Code,and,my license'is in full force and effect.
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Class • nn
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nse,Numbe Lia Class.
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Cont DateU
❑ Iam,exempt under Sec Plan check fee
B:&P.C.for this reason PERMIT.ISSUING FEE$ V
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Date
" ` ` TOTAL:-FEE
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Signature .7
4CL
- PLAN CHECK APPLICANT _ ••
OWNER-BUILDER DECLARATION.
.` I hereby affirm that-1 am exempt from the Co ntractor's''License Law.,,. 'NAME t
for the following reason (Section 7031.5, Business and Professions' D , 7 s• t
:Code). ADDRESS ,.: - r I;_ g'a?•
1, as.•owner'of'the.property'or my employees with'wages
as their sole compensation, will do the work and',the CITY TEL.NO.
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 i.
tion 7044,Business and Professions Code).
f I +
CITY :NC`
r
CONSTRUCTION'LENDING AGENCY f Rh
I hereby affirm that there is'a construction.lending agency for
the performance of the-wo,rk for.which this permit is issued CONTRACTOR D
(Sec.3097,Civ. C.).
ADDRESS 45 A
Lender's Name
Cl EL.NO.
Lender's Address STATE LIC. r
I certify that 1 have read this application and State that the above LICENSE NO CLASS
informationis 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
property gr inspectn purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
i ho
SIGNATURE OF APPLICANT OR AG T DATE - - -