HomeMy Public PortalAbout5803 ENCINITA AVE_Mechanical__ 'WORKER'S COMPENSATION a certificate
of consent to 2DA36,IC DPW 9189 APPLICATION FOR PERMIT . UME GREE]
2D-004 C
I ftereby 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 '/7I
copy thereof(Sec.3800 Lab. C.) - - -- - -
Policy No. -- Company COUNTY OF LOS ANGELES. DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. LLLIII
❑ Certified copy is hereby furnished.
Certified ified cais filed the county
nty building inspection FOR•APPLICANT TO FILL IN - BUILDING
department. (PRINT OR TYPE ONLY) ADDRESS -0,3 ENC N •74
Date Applicant LOCALITY p� r
PP NO. TYPE OF APPLIANCE OR EQUIPMENT � 'FEE ('i
CERTIFICATE OF EXEMPTION FROM WORKERS' - NEAREST p.
CROSS ST.
COMPENSATION INSURANCE
ABSORPTION UNIT,BTU ASSESSOR -
(This section need not be completed if thework involved by the - MAP BOOK PAGE PARCEL
permit is for one hundied dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NOPROCESSED By
. . y
('certify,that in the performance of-thewdrk far which.this permit � '-
is issued, I shall not employ any person in sky manner'so as to BOILER,BTU
become subject to the Workers'Compensation Laws. •7 L • - ���� `� �.'�
Q n / COMPRESSOR,BTU
Date —✓Rf�_ '/ Z Applicant •CiF in�Tle G 'VENTILATION SYSTEM APPROVALS GATE INSPECTOR'SSIGNATURE 1
NOTICE TO APPLICANT:. If, afl 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 y GRUITY
LICENSED CONTRACTORS DECLARATION / FLOOR BTU 3 VALIDATION
.'I hereby affirm that I am licensed.under provisions of Chapter 9 , ,
(commencing with Section 7000) of Division of the Business and HEATER: SUSPENDED UNIT_
WALL
Professions Code,and my license is in full force and effect.
License Number' '173Y Z/ Liu Class t�/ 210 U QUT/e ' -
, O -'9 'D� 101-
0Contractar[/A/, /sygeCDate
❑ ,_I am exempt under Sec. PIaf1 Check fee
B.,SP.C.for this reason _ PERMIT ISSUING FEE-$4n 1-5 O
Date: TOTAL FEE I - O
W
Signature - •. (L
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT (Q,
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
N.- fYt li c8 i
❑ I, as owner ofthe property, or my employees with wages tt ?']
as their sole compensation, will do the work and the CITY TEL.NO. H 1035 72
t+_ .
structure is not intended or offered for sale (Section 7044,.. _ ` j I-TEth
Business and Professions Code). OWNE7VA i. ! ' �• -1 -
I, as owner of tM1e property, 5 - 72
am exclusively conirading MAIL ' / /� TOTAL J-®
with licensed contractors to construct the project (Sec- ADDRESS - ��IG.. }_ T -, �',NEPt ZIIJ�1<
tion 7044,.BusinesS,and Professions Code). - Q.Q�/J M^ '` 1•f ,v.
CONSTRUCTION LENDING AGENCY CITU ar//L(//7 �w' V _ (''t.J�W;.)IDt .UO
herebyaffirm that there is a construction lending agency for- -§-
g. g CONTRACTOR - '
the performance of the work for which this permit is issued F
(Sec. 3097, Civ.C.). / ,
ADDRESS
0Ill
0l TI% 1,.I, -
Lender's Name CITY 17
Al
9159
/ ��Q
Lender's Address STATELIC:
I certify that I have read this application and slate that the above LICENSE NO.
information is correct. I agree to comply with.all County ordinances
and State laws
yyrelating to building construction,and hereby authorizerefp
to
jp,o ,yves tfor odspectiorCo�uPyySesenter upon'the above-mentionetlSEE REVERSE FOR EXPLANATORY LANGUAGE
OR AGEN