HomeMy Public PortalAbout9521 FLAHERTY ST_Mechanical__ WORKER'S COMPENSATION DECLARATION 76A364C 46DPW 9/89 APPLICATION FOR PERMIT LIME GREEN
76A3
I hertA';y affirnTdhat 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. 3880,0 Lab. C.)_
Policy NOQS�D /_0 CoC�m'any 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 FILL IN BUILDING
ADDRESS
department. (PRINT OR TYPE ONLY) ,y
Date Applicant LOCALITY'—
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
ABSORPTION UNIT,BTU ASSESSOR
(This section need not be completed if the work involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($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. -O
COMPRESSOR,BTU
Date Applicant VENTILATION SYSTEM APPROVALS DATE INSPECTOR'S SIGNATURE
NOTICE TO APPLICANT: If, after 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 GR ITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU �®t'Scao VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED—UNIT—
(commencing
USPENDED UNIT(commencing with Section 7000)of Division 3 of the Business and HEATER: WALL p
Professions Code,and my license is in full force and effect. +1
D
License Number O Y Lic.Class C' AC•GTeg
3303 114.10>.
Contractor Date �/ �2 ��i 1 ITEMS V
❑ I am exempt under Sec. Plan Check fee TOTAL g ¢ ® ��1=
B.&P.C.for this reason PERMIT ISSUING FEE $ CHECK 114.1J0
Date: TOTAL FEE /�j CHANGE „i ll LU
Signature 113-'
PLAN CHECK APPLICANT CD
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law NAME 0000-0001 6!12!96—
for the following reason (Section 7031.5, Business and Professions �7 8,-
b i AM 9=0
16
Code): . ADDRESS
❑ I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale'(Section 7044,
Business and Professions Code). OWNER
❑ 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). r- L
r�
CONSTRUCTION LENDING AGENCY CITY TEL.NO. R� yrS J
I hereby affirm that there is a construction lending agency for CONTRACTOR zl
the performance of the work for which this permit Is issued
(Sec.3097, Civ. C.).
ADDRESS
Lender's Name
CITY TEL.NO. /L
Lender's Address STATE LIC.
I certify that I have read this application and state that the above LICENSE NO. 2 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 topnter upon the above-mentioned
property for inspect' n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
(n .
SIGNA OFA ICA O GENT DATE