HomeMy Public PortalAbout5114 DOREEN AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT
' d hereby affirm that I hgve a certificate of consent id self
insure, or a certif+cate bf Workeis' Compensation Insurance,' 76A364C HEATING - VENTILATING AIR CONDITIONING ,
or a-certified copy thereof (Sec. 3800, Lab. C.) ..
}^" _
20-0046 DPW 9/88
Policy No.—Company
P�
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
.❑ Certified copy is filed with the county building inspec- . FOR APPLICANT TO FILL IN IU DN /,I/
tion department. .. ADDRESS dl? /T
(PRINT OR TYPE ONLY) -
Date Applicant LOCALITY
• - NO. TYPE OF'APPLIANCPOR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
. - PDBY
-, (This section need not.be.completed it the work involved by ABSORPTION UNIT, BTU DISTRICT NO. RCC
the permit is for"one hundred dollars ($100) or less.) _
!g/
I certify incur HANDLING UNIT, CFM
t in the performance of the work for which this � O V
permit is issued, I shall not employ any personry in any manner
BOILER, BTU
so as to become subject to the Workers Compensation Laws
APPROVALS +DATE INSPECTORS.SIGNATURE
�1 L- COMPRESSOR, BTU O V /
Date. -3- (� Applic, j'j ROUGH
U
NOTICE TO APPLICANT: If, after .making this Certificate,.of VENTILATION SYSTEM FINAL
Exemption, youshould become subject to the Workers'
Compensotion-provisions of the Labor Code, you must forth EVAPORATIVE COOLER -_ VALIDATION
with comply with such provisions or this permit Shall be deem- - -
ed revoked. - :- FURNACE: TAU V TY _ 0
' LICENSED CONTRACTORS DECLARATION FLOOR U (f
(hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT_ -
(commencing with Section 7000)of Division 3 of the Business WALL -
xi and Professions Code,and'my license is in full force and effect. C.
ICE.
License Number _Lic. Class D O
V
Contractor Date
❑ O
am exempt under Sec
Plan check feeU_ �
BAP.C. for this reason: W
a
PERMIT ISSUING FEE $ un
' - Date: Z Z ,
Signature TOTAL FEE 00
OWNER-BUILDER DECLARATION PIAN CHECK APPLICANT -
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and NAME ST�� C-✓G�' D -
P o ssions Code): _
ADDRESS -/�fiO S'z /7h �GL� /1-VV.i_
IV I, as owner of the property, or my employees with n s
woges as their sole compensation,will do the work and CITY OK TEL N pk�T Z AUT/� •*
the structure is not intended or offered for sale Section Q ��Z / a C,O
7044,.Business and Professions Code). ,(¢¢ K07 - `'r'LITE
OWNER.:l.Alvl�•. /T Y�v�. 9
.❑, I, as owner of the property, am exclusively i ITERS
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS -
TOTAL 59 - 00
CONSTRUCTION LENDING AGENCY CITY TEL. NO, - f Ft
I hereby affirm that there is a construction lending agency for D_ CHECK.
the performance of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.). gyp /s 7y�p , t�:HRMft
ADDRESSeIWI F,1 G4(11,p`/ ..
Lender's Name
Lender's Address r'
CITY TEL. NO. 0000-00cli Si 51;�Cl
_
certifythat have read this application and state that the STATE ' - LIC. ,t..r 5
pP LICENSE NO. CLASS I Illi 'a�I!
above information is correct. agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter -
upon t above- entioned property inspectionpur s.
ary 3 SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of,APPlimnt or Agent Date ' ®s