HomeMy Public PortalAbout9849 FLAHERTY ST_Mechanical__ WORKER'S COMPENSATION DECLARATION 46 DPW 9/8s APPLICATION FOR PERMIT L E GREEN
76A3
I hereby affirm that I have a certificate of consent to self insure, 76A364C
or a certificate of Worker's Compensation Insurance, or a certified HEATING - VENTILATING-AIR CONDITIONING
copy thereof(Sec. 3800 Lab. C.)
�
t"-cy No. �jq 4,,L,3(g
t eiQany COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
Certified co is filed with the count buildinginspection FOR APPLICANT TO FILL IN BUILDING
department. y p (PRINT OR TYPE ONLY) ADDRESS 9649 listrelin
s ,r 1 � r r LOCALITY
Date dye!Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE -
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST u
COMPENSATION INSURANCE CROSS ST.
ABSORPTION UNIT,BTU ASSESSOR Baill
It
(This section need not be completed if the work involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to I BOILER,BTU
become subject to the Workers' Compensation Laws.
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATERSUSPENDED
:
(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code, and my license is in full force and effect.
E L.♦. t,.s lEy ya •A .Q.
License Number t«.: x.1—J Lic.Class
a
Contractor Date
❑ I am exempt under Sec. Plan Check fee V
W
B.&P.C.for this reason PERMIT ISSUING FEE$ J
LL
Date: TOTAL FEE }
Signature
PLAN CHECK APPLICANT Q
OWNER-BUILDER DECLARATION c
I hereby affirm that I am exempt from the Contractor's License Law NAME , 0
for the following reason (Section 7031.5, Business and Professions CL
Code): 2
El
W
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
F-1 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).
CONSTRUCTION LENDING AGENCY CITY ylty TEL.NO.
I hereby affirm that there is a construction lending agency for CONTRALTO ,
the performance of the work for which this permit Is issued _ y
(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name
CITY r. t - TEL.NO, 3,
ian
Lender'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 construction,and hereby authorize
representatives of this County to enter upon the above-mentioned
property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APPLICANT OR AGENT DATE