HomeMy Public PortalAbout9156 FORTSON DR_Mechanical__ WORKER'S COMPENSATION DECLARATION 200046 DPW 9/89 APPLICATION FOR PERMIT
76A364C LIME GREEN
I hereby affirm that I have a certificate of,consent to self insure,
E�.-
or•a.certiflcate of Worker's,Compensatlon_Insurance; or a certified HEATING-VENTILATING -AIR CONDITIONING ".
. -
copy.thereof(Sec 3800 Lab.CJ , ., '. .. .' ', .. •• ,,- •• ;
Policy Nzwlq I=Fcompany �-+g-`�a�-- COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS; BUILDING AND SAFETY DIV.
❑ Certified copy Is hereby furnished.
1 . S BUILDING
' Certified copy is filed with the county b ' FOR APPLICANT JO FILL IN ADDRESS
(PRINT OR TYPE ONLY)
Date Apphant'^� �+j� LOCALITY' �i J
_ - cTYPE OF APPLIANCE OR EQUIPMENT, FEE ,
CERTIFICATE OF EXEMPTION FROM,WORKERSNEAREST
ST
COMPENSATION INSURANCE , CROSS
' 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($100)or less.)', AIR HANDLING UNIT,CFM
•r. ✓. DISTRICT NO PROCESSS
.I certify that in the performance of the work for which this permit h
is issued,'I shall not employ any person in any manner so as to BOILER,BTU G vr_ yJ�
become subject to the Workers'Compensation Laws a V O V - c
I COMPRESSOR,BTU Z O `o
- .. APPROVALS DATE INSPECTOR'S SIGNATURE _•
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If:•after'making this Certificate of ROUGH
Exemption,you should become'subject to the Workers' Compensatidn EVAPORATIVE COOLER •v-�/
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this,permit,shall be deemed revoked FURNACE: FAU GRAVITY ! �%I�
LICENSED.CONTRACTORS DECLARATION FLOOR BTU VALID,+TION.=
hereby.affirm that,I am licensed under'provisions of Chapter 9 SUSPENDED• UNIT
(commencing with'Section 7000) of Division 3 of the Business and HEATER. WALL "
Professions Code,and my license'is in full force andteffect.
License Number Llc Class��'
d. a
Contracto f`
Plan check fee, t 0
❑ ' f
I am exempt under Sec 7� �
BAP.C.for this'reason PERMIT ISSUING-FEE$ /•^. 0
Date: TOTAL FEE i 'a �. U
LU
Signature
OWNER-BUILDER DECLARATION _ PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License Law NAME , wr''•. Z
for the following reason (Section 7031.5, Business and'Professlons "
Code): ADDRESS. u:_• E
❑ 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, ,,�� ., - I„f -,; '• -
Business and Professions Code). . OWNER - —
❑. I, as owner of the property, am exclusively contracting MAIL r.
with licensed.c rtractors to construct the project (Sec-- ADDRESS ;� '�`
tion 7044, Business and Professions Code). ` n
CONSTRUCTION LENDING.AGENCY CIT 421 1.��n TEL.NO
Ihereb affirm that there Is a construction lending agency for , "ti.;�? i ._,,tr'" }
the performance,of,the work.for which this permit Is issued CONTRACTOR _ ) --
(Sec.3097,Civ.C.). jiT(
ADDRESS
Lender's'Name• //^^��
CITY� T_ / / � TEL NO 4 /0
Lender's,Address STATE G V
I certify that I have read this application and state that the above LICENSE NO. CLASS
information,is correct. I agree to comply,wlth-all County ordinances
and State laws relating to budding construction,and hereby authonie
representatl of this County to enter upon the above-mentioned
Oro I ection purposes. ' " SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF A LIC TOR AGENT - DAT 1 - ,