HomeMy Public PortalAbout5805 1/2 ENCINITA AVE_Mechanical__ rmlWORKERrS COMPENSATION DECLARATION 76A348 DPW 9/89 APPLICATION FOR PERMIT. DME GREEN
I hereby elf irm.that I fieve a certificate of consent ro self insure, 76A366C
or a certificate of Worker's Compensation Insurance, or a certified - HEATING-VENTILATING -'AIR CONDITIONING
copy thereof(Sec.3800 Lab. C.) LLLIII
Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
❑ " ' '
Certified copy is filed with the county building inspection FOR APPLICANT TO IN BUILDING
ADDRESS
department. (PRINT OR TYPE ONLY)Y) ,
Applicant LOCALITY
Date
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE C•
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS NEARESTT . LAS TNN A-5
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
ASSESSOR
(This section need not be completed It the work involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT e0. PROCESSED BY
I certify that in the performance of the work for which this permit CCC,,,ppp
is issued, I shall not employ any person in any manner so as to BOILER,BTU ��� ^4/2
become subject to the Workers'Compensation Laws. - /
COMPRESSOR,BTU OLID
�l APPROVALS HATE INSPECTOR SIGNATURE,
Date • Applicant 9-/0 �2 ` VENTILATION SYSTEM
NOTICE TO LICANT: 11, atter making this Certificate of ROUGH QJi
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 CONTRACTORS DECLARATION FLOOR. BTU 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 Code,and my license is in full force and effect.
S7� /� '7 J�
License Numberr "� Lia Class�
(L
Contractor CAS C4;MA7e1 Date 9-lU '- 92, V
❑ Plan check fee ,
I am exempt under Sec. Q
B.BP.C.for this reason PERMIT ISSUING FEE /f U
Date: TOTAL FEE. '. - d
Signature PIAN CHECK APPLICANT
OWNER-BUILDER DECLARATION - Z
I hereby affirm that I am exempt from the Contractor's License Law NAME
for the following reason (Section 7031.5, Business and Professions
Code): ADDRESS
❑ 1, as owner of the property, or my employees with wages - -" ?31)7 105.72
as their sole compensation, will do the work and the CITY TEL.NO. „- 1 ITEMS
structure is not intended or offered for sale (Section 7044, '
Business and Professions Code). OWNER - '` AC 'f
❑ 1, as owner of the property, am exclusively contracting M Ctio VITAL - 19..Js .
project
( MAIL Li4C,eFiGGQ - GFiECii 1_t t"
with licensed contractors to construct the ro'ect Sec- ADDRESS (I.I,
lion 7044, Business and Professions Code). CITY T . " (. ,I If
CONSTRUCTION LENDING AGENCY A7LCX} /A /00 S ��• HANGE
hereby affirm that there is a construction lending agency for
the performance of the work for which this permit Is issued CONTRACTORCAL 61wln,4re,
(Sec.3097,Civ.C.). (, �1,.."J -"'. " ' •"• rL r1 p r
ADDRESS '770 7 F/a//( 2CGn/ C.IfII](,I-yOJi ',l/'11V4�_
^..
Lender's Name CITY T L " ..C4.y" 1 �'AM-•?.959
R2CAa/A /006 lft V",,5
Lender's Address STATE . LIQ
I certify that I have read this application and state that the above LICENSE NO. SL CLASS C '� LO ,
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 "
pro ty f inspectio urpoSEE. SEE REVERSE FOR EXPLANATORY LANGUAGE'
9�0 - 9v
51 ATURE OF NPPLICANT OR NT DATE