HomeMy Public PortalAbout6426 ENCINITA AVE_Mechanical__ I WORKER'S COMPENSATION DECLARATION 20.00 4DPW 9/89
76A364 APPLICATION FOR PERiViIT• ,�� GREEN
C
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 thdrbof(Sec.3800 Lab:C.)
Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS - BUILDING AND SAFETY DIV. .
❑ Certified copy is hereby furnished.
F-1 Certified Copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING \ /'
ADDRESS v� t4
department. � (PRINT OR TYPE ONLY) •
Date Applicant - LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT ,�FEE '
GERTIFICATEOF EXEMPTION FROM WORKERS' NEAREST
CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU -
(This section need not becompleted if the work involved by the MAPE
SSOR
bBOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTR . ••
ICT NO. PROCESSED BY
I certify that,in the performance of the work for which this permit
is issued I shalllnot employ,any person in any manner so a to BOILER,BTU G
become subject to the Workers'Compensation a.
r
COMPRESSOR..BTU /D9
pGPPpVALS DATE INSPECTOR'S SIGNATURE
Date - ..Applicant VENTILATION SYSTEM
;NOTICE TO APPLICANT: If, atter making this Cert' icate of - r ROUGH
Exemption,ybu should become subject to the Workers• C pensation 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 affirmthatl am licensed under provisions of Chapter 9 SUSPENDED � _ UNIT_.
(commencing with,Section 7000) of Division 3 of the Business and EATER: WALL
Professions Code,-and my license is in full force End effect.
ACCT.4
License Number' Lic.Class 3303 53,90
D 1 ITEMS a
Contractor Date • O
❑ I am exempt und Sec. - Plan Check fee' - TOTAL c3 91D V
BARC.for this reason PERMIT ISSUING FEE $ p CHECK- 53.90 0
Dale: p CHANGE .00 0
TOTAL FEE / .. .W
Signature d
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT ••fA
0000-0001 5�.4/,9b z
1 hereby affirm that 1 am exempt from the Contractor's License Law NAME ii
for the following reason (Section 7031:!5, Business and Professions D 70,D,3 '1 FM 5:45
Code): - ADDRESS
❑ I, as owner of the property, or my employees with wages _
as their sole compensation,,will do the work and the CITY ' C,I - TEL.NO. - -
structure is not intended or offered for sale (Section 7044, � /
Business and Professions Code). OWNER IN
❑ 1, as'.owner of the property, am exclusively contracting MAIL
with licensed contractors to co nsiruchthe project (Sec- ADDRESS ,
( lion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY 'TEL.NO. '
I hereby affirm that there is a construction lending for'
agency cy CONTRACTOR
'
the performance of the work for which this permit Is for
(Sec.3097, Civ. C.). -
ADDRESS '
Lender's Name
CITY TEL.NO.
Leader's Address .STATE LIC. - - -
I certify that I have read this application and state that-the above LICENSE NO. CLASS
information is correct. I.agree to comply with all County ordinances
and State laws relating to building co struction,and hereby authorize
representatives-QI this County to ter upon the above-mentioned
property for i (pact purpose SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APPLICANT OR AGENT DATE