HomeMy Public PortalAbout9855 FLAHERTY ST_Mechanical__ WORKER'S COMPENSATION DECLARATION 46DPW 9/89 APPLICATION FOR PERMIT LIME GREEN
76A3
I'hereb7l affirm,tfiat 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.
33800 Lab. C.)
Policy No. 10`f / ?'2 Company : h 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 jY
department. �i (PRINT OR TYPE ONLY)
Date Applicant I ' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
ASSESSOR
(This section need not be completed if the work involved by the MAP BOOK / PAGE�PARCELQ�'�
permit is for one hundred dollars($100)or less.) - AIR HANDLING UNIT,CFM -
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU J�D�
become subject to the Workers' Compensation Laws.
!( / COMPRESSOR,BTU
Date 10—}i Applicant 1f APPROVALS DATE INSPECTOR'S SIGNATURE'
NOTICE TO APPLICANT: If, after making this Certificate of ��r d"b ROUGH d
Exemption,you should become subject to the Workers'Compensation
EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such �3 � FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code, and my license is in full force and effect.
License Number J� ZT a� Lic.Class �- O
Contractor ( ►►-� TI"-�'r Date {CzIk_4^0 , L
� O
❑ ia8 U
I am exempt under Sec. Plan Check fee 3I�1 105.`i
BAP.C.for this reason PERMIT ISSUING FEE$ L� ;� I 1 O
Date: I O
TOTAL FEE T'TTL 105-72 w
Signature �= - -�2- - ir, n-
OWNER•BUILDER DECLARATION PLAN CHECK APPLICANT CASH 10•�o r i Z
I hereby affirm that I am exempt from the Contractor's License Law NAME I. h'� 4+V I►-�I�- , CHANGE a 00
for the following reason (Section 7031.5, Business and Professions /y
Code): ADDRESS -AVE-
asas owner of the property, or my employees with wages �" 7
as their sole compensation, will do the work and the CITYa�� TEL.NO. _S,53a 0000`0001 101 30.1K'
structure is not intended or offered for sale (Section 7044, �t ,•t
Business and Professions Code). OWNER �� J,j> yS,w 6277 1 AN a1
❑ 1, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS U!!✓ �T
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TSCA CAT r-/ TEL.NO.
I CO
hereby affirm that there is a construction lending agency for CONTRACTOR
the performance of the work for which this permit Is issued �f`-tQ j►J 4�
(Sec.3097,Civ.C.).
ADDRESS
Lender's Name
CITY TEL.NO.
Lender's Address STATEFF LIC.
I certify that I have read this application and state that the above LICENSE NO. J2 �� 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
Q a- -
SIGNATURE OF APPLICANT AGENT DATE