HomeMy Public PortalAbout4523 ELLIS LN_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046 DPW
PW 9/89 Alf'UCA 11 I®n n ®� �����T a
I hereby affirm that I have a certificate of consent to.self insure,
or a certificate of Worker's Compensation Insurance, or a certified HEATING -VENTILATING-AIR CONDITIONING,
copy thereof'(Sec.3800 Lab. C.) -
Policy No. Company COUNTY OF LOS ANGELES. _ DEPT-OF PUBLIC WORKS BUILDING,AND SAFETY DIV.
Certified copy is hereby furnished.
' BUILDING "�Z: �•• .�� .���
Certified copy is filed with the county building inspection FOR.APPLICANT NT ONLY) IN ADDRESS
department. (PRINT
LOCALITY
Date ` Applicant "' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST 4 '
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST.
COMPENSATION INSURANCE
ABSORPTION UNIT;BTU - - -
ASSESSOR
(This section need not be completed if the work..involved by the. � ,- ': MAP-BOOK PAGE' PARCEL
permit is for one hundreddollars($100)or less.) '.AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED 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
become subject to the Workers''Compensation Laws
CQMPRESSQR;,BTU APPROVALS DATE INSPECTOR'StiSIGNATURE
Date Applicant VENTILATION SYSTEM,
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH r. '
Exemption,you should become,subject to.the.Workers'Compensation' EVAPORATIVE COOLER- ,
,provisions of the Labor Code,-you must forthwith•comply with such FINAL g 9
provisions or this permit shall be deemed revoked. FURNACE:: FAU GRAVITY
LICENSED'CONTRACTORSbECLARATION FLOOR BTU •• VALIDATION.
I hereby affirm that I`am'licensed under provisions of Chapter 9 - SUSPENDED UNIT
,(commencing with Section 7000)'of bivision 3-of the Business and HEATER: WALL
_Professions Code,and.my license is in'full force and effect.
License Number Lic.Class
CL
Contractor'7, Date O
❑ I,am exempt under Sec..' Plan Check fee �v. O
B.&P.C.for.this reason PERMIT ISSUING FEE O
bate: TOTAL FEE W.
Signature ACC a 8CD
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT •1 109.'55 z
hereby'affirm that I am exempt from the.Contractor's License Law NAME -L_(
for the following reason (Section 7031.5, Business and Professions " I ,ITEMS
Code): ADDRESS TOTAL .109
.. .1§�
❑ I, as owner of.the property, or my employees'with wages ,, .a_a .;
as their,sole com ensation, will the work and the TEL.NO. {S o Y
p CITY L
Business and Professions structure is not intended r offered for sale (Section 7044,., OWNER,
C PW S LLI S a CHANGE ,0{�:
❑ - Y' ... ,
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). _ ���� ry �y �yg !/ C ��yy�
CITY-� 'TEL.NO.. �[�[ /. / L000-000L 1{i!�71
CONSTRUCTION LENDING AGENCY EIYI LG 1 T7 J'G. 1 i' i i
I hereby affirm that there is a construction'lending agency for D! 7SI�,S ' PM1'�*1rt
the performance of,the work for which this permit Is issued, CONTRACTOR
(Sec.3097,Civ.C): f ..
_ .. ADDRESS
Lender's Name
CITY
Lender's Address
STATE. LIC.
certify that I have'read this application and state that the above 'LICENSE NO. CLASS ! t'
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 c,enter upon the above-mentioned
.- . .
property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APPLICANT OR AGENT DATE