HomeMy Public PortalAbout10650 DANBURY ST_Mechanical__ WORKER'S COh!P' JSATION DECLARATION 20-0046 DPW 9/09
6A364C APPLICATION FOR PERMIT
• 'I hereby'Ef Rnn 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.) -' - - '- - t ' •� �.:
Policy No. ,Company , �ii� COUNTY OF LOS ANGELES • DEPT OF PUBLIC WORKS BUILDING AND SAFETY,DIV
'Cerlitled copy is.hereby furnished. -
❑ ' . Certified copy is filed wittrihe'county'builtling inspection, FOR APPLICANT T FILL IN BUILDING �Q'Ea ��
d
� epadmenLA (PRINT DR.TYPE ONLY)
ADDRESS
- -
ApplicantLOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS'r NEAREST e'
COMPENSATION INSURANCE CROSS ST.
e � ABSORPTION UNIT;BTU _ ASSESSOR
(This testier need not ed completed(Sl if the work involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars(SlOil less.) AIR HANDLING UNIT,CFM Ds"'NO, PRocEsseO ev
I certify that in the performance of the work for which this perm '
is issued, 1 shall not employ any person in any maner so it
nas BOILER,BTU •• 'L�mQ Ce^C-!�"'�`'
become subject to the:Workers' Compensation Laws
r - COMPRESSOR,BTU
Date Applicant _ - APPNovALS -DATE INS1FGTOu's SIGNATURE
- Pp VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate's of ROUGH
Exemption,you should become subject to the Workers'CompensationEVAPORATIVE COOLER 12
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE FALL GRAVITY / VALIDATION
LICENSED CONTRACTORS DECLARATION / FLOOR BTU '>,SOQO D ,.
I her Eby_affirm that I am licensed under,provisions of Chapter,9 SUSPENDED UNIT_ '
(commencing with.Section 7000) ofDivision`3 of the Business and HEATER: WALL
.Professions Code„and my license is,in•full force and effect. - '
License Number �57� Lic.Class_.� _• / ���
Contractor � Date—p—��_L� iy „I g -
• - . ' Plan check fee a '+
lam exemptuntlarSec. K/- „{_' yl l�,�i_
B BP:C.for this reason PERMIT ISSUING FEE$ * A '
11,et U
Date: TOTAL FEE l i t jl 10 m O— W
a
Signature _ - a
PLAN CHECK APPLICANT ;;-SEC K <(IV CIC
OWNER-BUILDER DECLARATION ' - Z
• I hereby affirm that Lam exempt from the Contractor's'License Law' NAME D r 1:11{I_� CC
for the following reason (Section 7031'.5, Business and Professions - -
Code). - ADDRESS - -
❑ I, as owner of the property, or my employees with wages' - - �y( ,11 L(l_Si t” 7, 1 �•
as their'"sole'compensation, will do the work and the CITY TEL.NO. ""
structure is not intended or offered for sale (Section 7044: 1 4i`1 rli'?'.
Buttress and Professions'Code).. OWNER -
❑ I, as owner of.the property, am exclusively contracting. MAIL �y/��y ^�
with licensed.contractors to construct the project.(Sec- ' ADDRESS xe
- tion 7044,Business and Profession s.Code). -
CONSTRUCTION-LENDING'AGENCY
CITY �• TEL.NO.
hereby affirm that there is a construction lending agency for CONTRACTOR
the performance of the work for which this permit Is issued / -
'(Sec.3097 Civ.C.). 5."
ADDRESS .. _
Lender's Name J '
CITY TEL.NO' ✓
Lender's Address ,STATE _. LIC. /-�•'
-. _ - .. ,... ,.,.a..
I certify that I have read this application and state that the above LICENSE NO. %,$—�� CLASS f -
information-is correct. I agree to comply with all County ordinances
and State laws relating t0 building construction,and hereby authorize - ' . . '^.•
representatives of this County to enter upon the above-mentioned
property fo 'ts -c' uiposes. SEE REVERSE FOR EXPLANATORY LANGUAGE s
OF APPLICANT Oa AGENT. .. A y