HomeMy Public PortalAbout9162 FORTSON DR_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/99 APPLICATION FOR PERMIT
76A364C LIME GREEN
hhereby a ffirm-that,l ,"ve'a certificate of consent to self insure', ,
"or,a certificate of,Workers:Oompensation Insurance; or a certified - - HEATING -VENTILATING--AIR CONDITIONING
copy thereof(Sec.3800'Lab.C.)" -
Policy No. ,L�- _y? b 3 Company COUNTY OF LOS ANGELES •DEPT OF PUBLIC WORKS BUILDING AND SAFETY-DIV.
❑ Certified copy is hereby furnished.
El Certified co is filed with the couht 'buildin inspection . FOR APPLICANT TO FILL IN BUILDING
copy y g p ADDRESS �7
department. -, (PRINT OR TYPE ONLY) 2 �Z7S
Date �2 `_ LOCALITY,;, l�x
Applicant
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE'OF EXEMPTION,FROM WO KERS' NEAREST
CROSS ST
COMPENSATION INSURANCE ;i. ABSORPTION UNIT;BTU '
(This section need not be completed if the work involved by the ASSESSOR '
MAP BOOK PAGE PARCEL,
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM' OisTRicTNo, PRoeesseo BY
I certify,that in the performance of the work for which this permit'
is issued, I shall not employ any person in any mariner so as 11 to BOILER,BTU CJ ;
become_ subject to the'Workers'Compensation Laws
COMPRESSOR,BTU to
„ APPROVALS , DATE INS TORS SIGN URE,
Date' Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT, If, after making this Certificate.of ROUGH
Exemption,you'should become subject to the Workers'Compensation
EVAPORATIVE COOLER.'
provisions of the:Labor,Code,' you-must forthwith comply with such FINAL t
provisions or,this.permit shall,be deemed revoked FURNACE: FAU GRAVITY
LICENSED CONTRACT,ORS'DECLARATION , FLOOR BTU � _ ,01C) VALIDATION
I hereby affirm that 4-am licensed under,provisions of'Ch'apter 9 SUSPENDED UNIT • '
((commencing with Section 7000) of Division 3 of'the Business and HEATER, WALL
Professions-Code,and my'license is in full'force and effect.
License Number e/ Lic:Class
Contractor Date Z
❑ I am exempt urAer ec. Plan.Check lee V
• 1 B.BP.C.for this reason PERMIT ISSUING FEE.$
Date. TOTAL FEE : U
-al W
Signatured
OWNER-BUILDER DECLARATION PLAN CHECK•APPLICANT Op N CO
I hereby affirm that I am exempt from the Cbn racfor'S'LIcen3e Law NAME' oil.
G! Z
for the following"reason (Section 703115,'Business'and Professions _
ACCT JL . , .
. ADDRESS ■
Coe e
I, as owner of the properrty, or my employees with-wages •� t(1y
as-their sole com ensation, will,do the"work and the0�? 11J9o90^
P CITY TEL.NO h
structure is not intended'or offered.for sale (Section 7044, =•1'ITEMS
Business and Professions Code). OWNER €3
9 .
❑ I, as owner•of the property,'am exclusively contracting TOTAL ��7 m �
p , ( MAIL CHECK 10949.0
with licensed contractors to construct the ro'ect Sec- ADDRESS
tion 7044, Business and Professions Code) - CHANGE
CONSTRUCTION LENDING AGENCY CITY TEL' NO CHANNGG E VV•'
I.hereby affirm that there is a construction lendingagency for " 'CONTRACTOR
th'e`performance of the work for•which this permit is issued
(Sec;3097,Civ. C,)., ,
ADDRESS 2 ,0000-0001 '.-•10/12/95"
L'ender's Name 2761 1 . .AM 11%11
CITY- , 'TEL NO
1-7 410 ;
Lender's Address Ji
STATE- / _ LIC
certify that I have read this application and state that the above LICENSE NO� ^d7 b s 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 ^
!1IGNATU APPLI NT AGENT DATE - '