HomeMy Public PortalAbout10815 FREER ST_Mechanical__ DECLARATI
WORKER'S COMPENSATION a certificate
of consent to 76A346DPW9/89 APPLICATION FOR PERMIT LIME GREEN
: 76A364C
I hereby affirm that I have a certificate of consent to self insure,
o�a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
Copy thereof(Sec.3800 Lab.C.)
Policy No l//&Idr7 Compan 6,=4i"� � COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS. BUILDING AND SAFETY DIV.
Certified copy is hereby furnished. BUILDING
❑ Certified copy is filed with the county building inspection FOR.APPLICANT TO FILL IN ADDRESS
epartment _ (PRINT OR TYPE ONLY)
i �^' ✓ LOCALITY �
Date / Applican NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE.OF EXEMPTION FROM WORKERS' NEAREST
CROSS ST. ..
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
This section need not be com leted if the work involved b the ASSESSOR
( P Y MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY -
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws.
l COMPRESSOR,BTU d /J
t� APPROVALS - DATE ' .. INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH 42 A
Exemption,you should become subject to the Workers' Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU gref GRAV TY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
/�- D0 If ATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect.
License Numb `// Lic.Clas
y , 0
Contrac ate V
I am exempt under Sec. Plan check fee. cc
O
B.&P.C.for this reason PERMIT ISSUING FEE$ ��QQ U
Date: TOTAL FEE a LU
Signature PLAN CHECK APPLICANT ct)
OWNER-BUILDER DECLARATIONz
i;
I hereby affirm that I am exempt from the Contractor's License Law NAME _
for the following reason (Section 7031.5, Business and Professions , t;' s
Code): ADDRESS,
I, as owner of the property, or my employees with wages k:1j3
as their sole compensation, will do the work and the CITY TEL.NO. s '•
structure is not intended or offered for sale (Section 7044, i f '=
Business and Professions Code). OWNER I_I � y_5 00
I,'as owner of the property, am exclusively contracting MAIL I
with licensed contractors to construct the project (Sec- ADDRESS
NECK cco?
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TEL.NO. i. j�7r ,1 sl._
I hereby affirm that there is a construction lending agency.for
I performance of the work for which this permit Is issued CONTRALTO A
(Sec.3097,Civ. C.). : „ Poo. !ti I)ii) 3 I'1i •c
/� ADDRESS -
Lender's Nan/�l!L� tel!! y � A ��/ 7 _4 � ��, x
j/{� t //,/��yy'�� CITY � f�✓�••_ TEL.N ,/II +.`-^�-D 13
Lender's Address/�/ r /� W�`wYaQ� STATE !iK LIC. IV
certify that I have read this application and state that the above LICENSE NO 7 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 insp ction /I /J•/ SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE-OF AP1CANTOR AGENT_ -- - - - -- DATE� � '` — - - - -- ----- - - -- -- -- ---- - - .. _