HomeMy Public PortalAbout5211 DOREEN AVE_Mechanical__ WORKER'S I have
COMPENSATIONcertificate
DECLARATION 26A6ii DPW 9/89 APPLICATION FOR PERMIT WRE GRFERn
I hereby affirm that I have a certificate of consent to self insure, 7fiA3e6C
or a certificate of Worker's Compensation Insurance, or a certified HEATING - VENTILATING - AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.) u
Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Candied copy is hereby furnished.
❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN AooFE33
department. (PRINT OR TYPE ONLY) r
Date ApplicantLOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEARES
CROSS
COMPENSATION INSURANCE G
ABSORPTION UNIT,BTU ASSESSOR
(This section need not be completed if the work Involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
OISTXICT NO. PflOLEsaEe By -
I certify That in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU � z �/
become subjec to the Workers'Compensation Laws. a
COMPRESSOR,BTU
Date plicant FPPRGVPLe ePTE INSPECTOae SIGNATUPE
VENTILATION SYSTEM
NOTI E TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY-
LICENSED
RAVITY LICENSED CONTRACTORS DECLARATIONFLOOR BTU /O 0 VA ATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATERSUSPENDED UNIT_
(commencing with Section 7000) of Division 3 of the Business and : WALL
Professions Code,and my license is in full force and effect.
ACCT.:
License Number
y�7lo.� Lic.aria , 3303 53.90 }
IL
Contractor�/J7fF/t��.a.d6�Date 1 ITEMS O
❑ I am exempt under Sec. Plan Check fee TOTAL .53-90 cc
B.BP.C.for this reason PERMIT ISSUING FEE$ p CHECK 53.90 0
Date: TOTAL FEE 3 O CHARGE .00 a
Signature IO
DECLARATION PLAN CHECK APPLICANT
0000-0001 A9h/122/95 �
I hereby affirm that I am exempt from the Contractor's License Law NAME , 2423 1 AM 834
for the following reason (Section 7031.5. Business and Professions Cr
Code): ADDRESS
❑ I, 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 /v
❑ 1, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS / e F
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY Cm TY TEL.NO:
I hereby affirm that there is a construction.iending agency for CONTRACTOR ,
the performance of the work for which this permit Is issued
(Sec.3097, Civ.C.).
ADDRESS
Lender's Name
CIN&911111ella TEL.NO. _,;,O
Lender's Address STATE LIC.
I certify that I have read this application and state that the above LICENSE NO. 6 CLASS Q
information is 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 to pection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
7/� 3
MGNVUHVVF AP LI TO rt DATE