HomeMy Public PortalAbout4521 ELLIS LN_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9189 n PP��C n T�®nn ®A PER��y� /\/j\,y7� Em
76A364C - A5.1Al ,fl �f f II{) LI U� ..
I hereby affirm that I have a'certificate of consent to self insure, L� � '
or a.+ogerti'fica4of,Worker's Compensation Insurance, or a certified HEATING-VENTILATING -AIR CONDITIONING
copy thereof(sec.3800 La .-G:),_.
-G:)
/V V
.Policy No. J BUIL"DING AND SAFETY DIV.
Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS ,
Certified.copy is Hereby furnished.
Certified copy is filed with the county buildinginspection FOR APPLICANT TO FILL 1N BUILDING /_
P ADDRESS `J L�{11�t.,
departmeent/;'. �--,G (PRINT OR TYPE ONLY) - -
" - - Q� OLOCALITYN �Dae Applicant FEE'• a.
CERTIFICATE.OF'EXEMPTION FROM WORKERS' NEAREST:
• CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
This section:need not be com leted, Y if the work involved b the ASSESSOR
( P MAP BOOK PAGE PARCEL
permiCis:for•.one hundred dollars.($100)or less.). AIR HANDLING UNIT,CFM
DISTRICT.NO. PROCESSED BY.
I certify that in the performance of the work forwhich this permit
is issued f shall-not employ any person in any manner so as to_ BOILER,BTU
become subject.lo the Workers' Compensation Laws. ' �d z_
��Gy lv O.
- COMPRESSOR,BTU - -
- - - - - APPROVALS DATE ' INSPECTOR'S SIGNATURE.
Date Applicant VENTILATION SYSTEM
NOTICEITO APPLICANT: 1f, after making this Certificate of ROUGH.
Exemption,.you should become subject to the Workers'Compensation42
EVAPORATIVE COOLER
provislons•oi4he Labor Code, you-must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. ) FURNACE.:.,*, FAU >- GBAVITY /
LICENSED CONTRACTORS DECLARATION 1 FLOOR BTU 'SO BP0 VALIDATION
I hereby affirm that I am licensed under provisions,of Chapter 9 SUSPENDED UNIT ;
(commencing with Section 7000) of Division 3 of.the Business'and HEATER: WALL-
Professions
ALLProfessions Code,'and my license is in full force and effect.
License Number LIc Class,
../�/4 ` �C O Date (2-~1�1. -�40 - ACCT e S n.
Contractors -.-, 107 t�10 O
❑ ,,:I am exempt under Sec: Plan Check fee - 3.543 e90 V
B.&P.C.;for this reason ' ' PERMIT ISSUING FEE$ (Q 1 ITEMS F-
Date: TOTAL.FEE g_� TOTAL 109 . 90 w
Signature.
CHECK 149.94 (L
PLANCHECK APPLICANT' - (J)
OWNER-BUILDER DECLARATION CHANGE ■44 Z
I hereby affirm that I am exempt from the Contractor's License Law NAME D
for-the following reason (Section 7031:5, Business and•Professions
Code
) ADDRESS
I, as owner of the:property, or my employees with wages 0444-4001 6/13/96
as theirsole compensation, will-do the work and the OITY TEL.NO.
6
078
1 AM8■'13'
structure is not intended.or offered for sale (Section 7044, u
Business and Professions Code).. OWNER
EJ I, as owner of,the.property, am exclusively contracting MAIL
with licensed contractors to construct,.the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
TEL.NO.
CONSTRUCITY.LIC LENDING AGENCY /v'"� -
I hereby affirm that there is a construction lending agency for
the performance,of the work for which this permit Is'issued CONTRACTOR ,<•'i
(Sec.3097, Civ.'C,).
ADDRESS
Lender's Name .//��
CITY Jyjvl,V /t O v/�- _ TEL.NO.j�y
Lender's Address STATE7 'L__Z LIC.
I'certify that I have read this application and state that the above LICENSE NO. vs� CLASS
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 ,
p Ioerty f r inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APPLICANT OR AGENT DATE .• ,