HomeMy Public PortalAbout4826 DOREEN AVE_Mechanical__ r WORKERS'COMPENSATION DECLARATION APPLICATION
PPLIC A TION FOR PERMIT
I herebyyaffirm that I have acertificatg of consent to self PY f9 A F�7 E( PERMIT
insure,-or a certificate of Workers' Compensation Insurance, - HEATING - VENTILATING - AIR CONDITIONING
w a certifiedcopy thereof Sec 3800,Lab, C)" 76A364C
L 20-D046 DPW 9/88 .
Policy Nrt mpany.� COUNTY OF LOS ANGELES BUILDING AND SAFETY
CeNified.<opy is hereby furnished_ - � ,
Certified'copy ivfiled with the cou a inspec- BUILDING
❑ ., FOR APPLICANT TO FILL IN
tion parime I. (PRINT OR.TYPE,ONLY) _ ADDRESS
Date s`Appliccm LOCALITY L�
NO TYPE OF APPLIANCE OR.EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' - -NEAREST
COMPENSATIONINSURANCE - CROSS ST.
..y - ABSORPTION UNIT, BTU
(This section need not be completed if the work involved by - OtSTRICT NO, """��' v EssEO av
thepermitis for one hundred dollars ($100) of less.)' - ^ , 0 f/ -
I certify that in the performance of the work'for which this - AIR HANDLING UNIT, CFM- {✓1 0
- permit is issued, I,sholl not employ any person inanymanner -
so as to become subject to the Workers Compensation Laws. - BOILER, BTU APPROVALS PATEL INSPECTOR SIGNATURE
ell
Date , Applicant - .COMPRESSOR, BTU," ROUGH IQ
• NOTICE TO APPLICANT: If, offer making ,this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to .the Workers' - - ,
Compensation provisions of the,Labor Code, you must forth- EVAPORATIVE COOLER VALIDATI N
with comply with such provisions or this permit sholl be deem- - - -
ed revoked. FURNACE: FAU_GRAVITY
LICENSED CONTRACTORS DECLARATION �• FLOOR BTU
m '
I-hereby off rim that am licensed under provisions of Chapter 9 r . / HEATER: SUSPENDED UNIT tf•1.
y (commencing,with Section;7000)of.Division.3 of the Business ✓ WALL
and Professions Code,and my license is in full fortGyA ndF ffect. +
a }
i 1
'License Number } 'ZLit Clhss d
- D _
Contractor�'I--0.l '�VviKDate 111.22,1D1 - W
❑ I am exempt under Sec. - 0
+ Plan check fee
t B.SP.C. for this reason.
a
Date: PERMIT ISSUING FEE $ Z
Signature - TOTAL FEE '
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT. - + -
I hereby of that I am exempt from the Contractors License -
Low for the following reason (Section'7031.5, Business and NAME
Professions Code): , D v
I, 'as-owner of the property, or my employees with ADDRESS
wages as their sole compensation, will do the work and A�'�'T•T
the structure is not intended or offered for sale (Section CITY - TEL, NO. - `a7 '- '--20'.513.7044, Business and Professions Code). OWNER
I, as owner of the property,am exclusively contracting ITEMS
with licensedcontractors to construct the project (Sec- MAIL =
tion 7044, Business and Professions Code). - .
ADDRESS TOTAL - 2Q a 50'
CONSTRUCTION LENDING AGENCY. CITY TEL NO. CHECK ?Q�5(
I hereby affirm that there is a construction lending agency for- • ..._ _..... `-
._ tI t1c :... ��la
the performance of the'work for which this permit is issued CONTRACTOR '- D. CHANGE 'VV'
(Sec. 3097, Civ. C). � _ - _ .. ,
ADDRESS
Lender's Name _ - Y
CITYEL. No. 0000-0001` 11/22/39
Lender's Address -
I certify that I have read this application and state shot the? STATE • -HC.' - - - _• - - 69,66 - 1 'AM 9*04
above information is correct. I agree to comply with all County LICENSE NO. CLASS
ordinances and State laws relating to building construction,
and.hereby out {esentotives of this Cc my to enter -
upon ih e-m! ci ell property for in e�(Iyon
��72- -SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date
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