HomeMy Public PortalAbout4909 FRATUS DR_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89 \, LIME GREEN'
I h�rebypffirm.thal I have a certificate of consent to self insure, 76A364C APPLICATION FOR PERMIT
Or a certificate of worker's Compensation Insurance, or a certified HEATING -VENTILATING-AIR CONDITIONING
copy thereof(Sec.3�800 Lab•C.) u
Policy No• LG' Company!!!kIA—I - u-D COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ C BUILDING rtified copy is hereby furnished.
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Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN ADDRESS
departtme - (PRINT OR TYPE ONLY)
Date4f_Qr L�
entj Applicant `Jt��r%T�"� LOCALITY 40/^'
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS SL
COMPENSATION INSURANCE
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($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant, VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect.
Ig ev
License Number 3 Lic.Class,
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Contractor Date V
ElI am exempt under Sec. Plan Check fee 0
B.&P.C.for this reason PERMIT ISSUING FEE$ 143 &V
Date: TOTAL FEE OO W
CL
Signature CO
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT - Y 1 C3�ien i; Z
I hereby affirm that I am exempt from the Contractor's License Law NAME _
for the following reason (Section 7031.5, Business and Professions ���''�`" , ACC I ,-T
Code): ADDRESS S T—`F I
EJ1, as owner of the property, or my employees with wages -i1 0.
as their sole compensation, will do the work and the CITY + a7V TEL.NO. •
structure is not intended or offered for sale (Section 7044, ^k
Business and Professions Code). OWNER TOTAL m
F] I, as owner of the property, am exclusively contracting MAIL , ( ri_J
with licensed contractors to construct the project (Sec- ADDRESS `,(, '
t•:�__
tion 7044, Business and Professions Code). "•H•�N �
CITY fw ' ( TEL.NO. CHAN
IGE
CONSTRUCTION LENDING AGENCY
I hereby 'affirm that there is a construction lending agency for CONTRACTOR
the performance of the work for which this permit Is issued
(Sec.3097,Civ. C.). t �il i—tj1�11 r }
ADDRESS t wry
Lender's Name .5504 1 AM r", �t i
CITY TEL.NO.
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
propel or inspec np reposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIG URE OF APPL ANT OR AGENT DATE