HomeMy Public PortalAbout5202 DEGAS AVE_Mechanical__ �/OFIKER'S COMPENSATION DECLARATION 20-00A6DPW 9/99 APPLICATION FOR PERfVIIT ���� �G3LC �11
I hers0y affirm that I have a certificate of consent to self insure, ]eA3a4C
or a certificate of Worker's Compensation Insurance, or a certified
copy thereof(Sec 3800 Lab.J A • `-HEATING -VENTILATING-AIR CONDITIONING
Policy No.U3�IZ-z►(Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN ADDRESS
dlPpa ment. .(PRINT OR TYPE ONLY)
Date��1/ Applicant r NO. TYPE OF APPLIANCE OR EQUIPMENT yFEE LOCALITY -T� .
CERTIFICATE OF EXEMPTION FROM WORKERSNEAREST '
COMPENSATION INSURANCE CROSS ST. -
ABSORPTION UNIT,BTU ASSESSOR
(This section need not completed the work involved by the MAP BOOK PAGE PARCEL
permit is for one hundreded dollars or less.) AIR HANDLING UNIT,CFM PBocess Dev
I certify that in the performance off the 0 the work for which this permit DISTRICT NO.
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws.
COMPRESSOR.BTU Date Applicant "PPPOOALs ogre INsescTORs slasnTDRs
VENTILATION SYSTEM '
NOTICE TO APPLICANT: It, 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 p _
provisions or this permit shall be deemed revoked. ' FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER:' - SUSPENDED UNIT_
(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code, and my license is in full force and effect.
License Number Mv�fs: Lia Clafs�
Contractor ate D O
❑ 1 am exempt under Sec. Plan check fee V
fS
B.BP.C.for this reason PERMIT ISSUING FEE$ f :` 0
Date: TOTAL FEEoil - - W
Signature [L
PLAN CHECK APPLICANT !*• "-' ?
OWNER-BUILDER DECLARATION - co
Z
D - -
hereby affirm that
fortheam exempt from the Contractor's License Law NAME (,
far the following reason (Section 7031.5, Business and Professions
❑
I, j Z
as owner of the property, or my employees with wages ADDRESS ;r
as their sole compensation, will do the work and the j•
P CITY TEL NO. i ly LC+_t:f_(
structure is not intended or offered for sale.(Section 7044, - ..
Business and Professions Code). OWNER
El `..
I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS
lion 7044, Business and Professions Code). . •-- Iryy
CONSTRUCTION LENDING AGENCY CITY` T€L.NO. -� _ -
11
hereby affirm that there is a construction lending agency for r - r'.
the performance of the work for which this permit Is issuetl CONTRACTOR Y
(Sea 3097,Civ. CJ. axi,41.0'e— D
ADDRESS 1 i - .• -- _
Lender's Name
CITEL.NO. ell-
Lender's
- - _
Lendei s Address STATE JJJJJJ LIC.
I certify that I have read this application and slate that the above LICENSE NO. CLASS
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize -
4I..A
nta' es of This County to enter upon the above-mentioned
spection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
E OF APPLICANT