HomeMy Public PortalAbout10531 FREER ST_Mechanical__ WORKER'S COMPENSATION DECLARATION 46 DPW 9/89
76A3APS"�ICATION FOR PERMIT UAAE
REE
(vv��I hereaffirm that I have a certificate of consent to self insure,
or a certlflcgte••of Worker's Compensation Insurance, or a 6ertifled HEATING -VENTILATING-AIR CONDITIONING
copy thereof e4kc.3800 Lab C)
tt;C s. 11 ``3�.�(v 1 C e
Polic No. Company )nnp 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
d partm nt. _ (PRINT OR TYPE ONLY) ADDRESS_ 1 •1
Date` Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
•
: COMPENSATION INSURANCE ABSORPTION UNIT,BTU CROSS ST.
(This,section need not be completed if the work involved by the ASSESSOR ;
permit•is for one hundred dollars($100)or less.),-!. MAP BOOK PAGE PARCEL
AIR HANDLING UNIT,CFM DISTRICT NO PROCESSED BY
I certify that.ln the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER ~
provisions of the Labor Code, you must forthwith comply with such FINAL,
provisions or thls•permit shall be deemed revoked. , FURNACE' FAU GRAVITY O
• LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT •
(commencing withiSection 7000) of Division 3 of the Business and HEATER WALL
Professions Code,'and mylicenseIs In full force and effect.
License Number ' U q I Llc Class- C ACCT e a
3303 80.10 }a
Contractor -�►�O(�Wp 9►_;- a Date ` T p� Q
El I am exempt under Sec. Plan Check fee _ 1.ITEMS, �. .V
TOTALS- Q
BAP.C.for this reason PERMIT ISSUING FEE$ QCHECY �0
,.
O
Date: TOTAL FEE _• G Q CHANGE ' v06 W
Signature
(n
OWNER-BUILDERDECLARATION PLAN CHECK APPLICANT Z
I hereby affirm that I am exempt from the Contractor's License Law NAME' , OM-0001 9/13/95 '
for the following reason (Section 7031 5, Business and Professions C
Code): ADDRESS 22/-f 0 ' 1 AM10:25
❑ 1, 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
❑ 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 AQ
TEL.NO
I hereby,afflrm that there is a construction lending agency for CONTRACTOR T �_/��✓ ,
the performance of the work for which this permit Is Issued
(Sec.3097,Civ.C.).
ADDRESS 1
Lender's Name 1 O� Q
CITY" i vT .:NO
/1' O- X04
Lender's AddressSTATE Q LIC.- -
I certify that I have read-this application and state that the above LICENSE NO S O� 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
�propertyr inspection es SEE REVERSE FOR EXPLANATORY LANGUAGE
F APPLI AN R A E PATE -