HomeMy Public PortalAbout9000 GARIBALDI AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 26-OW DPW 9/89
I hereby nMrm that I have a certificate of consent to pelf Insure,
APPLICATION FOR PERMIT LIME GREEN
or a 6.JMcate of Workers Compena itlon Insuronos, or a certmed HEATING -VENTILATING-AIRCONDITIONINGcopy thereof(Sea 3800 Lab.C.)
Policy.Nlo� Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certttled copy Is hereby fumbhed.
❑ Car~oopy Is feed with the oourrty buShcng Inapecfbn FOR APPLICANT TO FILL IN ADDRESS
(PFMIT OR TYPE ONLY)
LOCALITY
Data Applaam NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
C>RTlF1CATE OF DCEMPTION FROM WORKKEPB NEAREST
ST,
COMPENSATION INSURANCE ABSORPTION UNIT BTU
(This eactlon nand not be oompiated ff the work Invotvad by the 'MAPDDOK PAGE PARMAq!:j
permit fetor one hundred dopers(=100)or Isaa.) AER HANDLING UNfT CFM
ornncr No, rrncaesn BY
I certlfy that In the performance of the work for which this permit
Is Issued, I shall not employ any person In any man r so as to BOILER,BTU
become subject to the Worker' . Od
COMPREBSOC4 BTU
rrmowKe D,kTa ew"TUae
Det. VENTILATION SYSTEM
NOTICE TO APP ICA : If, a making t e Certifloa ROUGH �
Exemption,you should become to'the Workers'Compensation EVAPORATIVE COOLER
provislons of the Labor Code, u must forthwith comply with such FINAL
provlsfons or this permit shall be deemed revoked. FURNACE: FAU O
LICENSED CONTRACTORS DJ CLA:AT1 N FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter B HEASUSPE DED UNIT
(oommsnoing with Sectlon 7000) of DtvWon 3 of the Business andrMan
er WALL
Professions Code`,and my Iloenes Is In full foroe and
/e�ffecttj��
Lkwm Number(��1 Lk:.Claes cS ,
rontr.otorA�'S A i �. �J q $
❑ I am exempt under Sec. heck fee
& P.C.for Ihle reason PERMIT ISSUING FEE; (p Q
Dat« TOTAL FEE d
Skgrrehxe OWNEFEBUILDER DECLARATION PLAIN C�Ca(AP�ANT Z
I hereby affirm that I am exempt from the Crontraotore Lloenso Law NAME
for the following reason (8eotion 7031.6, Bualnaee and Professions
Coda):❑ ADDRESS ACCT.4
■
I, as owner of the property, or my employees with wages
as their sole compensation, WIII do the work and the CITY TEL NO. �'-hr 11U•� l
structure Is not Intended or offered for sale (Section 7044, 1 1 EM
7
Business and Professions Code). OWNER j .1TCe1 h7
❑ I, as owner of the property, am exclusively contracting M/11L 1 TOTAL 1 it�1 - 20
with licensed contractors to construct the project (Seo- ADDRESS
f { 11�. J
116n 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY cmy.. TEL •C(l
I hereby affirm that there Is a construction lending agency for ,
I performance of the work for which this permit Is issued 5
(Sec.3087, Gv.C.). -
"D°REBs 1 y 13CA.-300 1 6/20/?4
Lenders Name
CITYNA M N U Te 1 W1 1:4?
Lenders AddressSTATE LIC.
I cert ty that I have read this applloation and state that the above LIC IE NO. CLASS
Infatuation Le=TeoL I agree to compy with all County ordlnencee
and State kawe building consbixliort,and hereby authorize
rep f My to eater u the above-mentioned
ro r urpoaea. SEE REVERSE FOR EXPLANATORY L.ANQUACiE
i