HomeMy Public PortalAbout9563 GARIBALDI AVE_Mechanical__ W�S COMPENSATION DECLARATFON' DPW G/BO
I-heFsp¢ .4 lrm that I have a certificate of consent to self Insure, APPLICATION FOR PERMIT LIME GREEN
or a-o rt"e of Worker■ Compensation Insurenoe, or a oertlflad HEATING -VENTILATING-AIR CONDITIONING
copy thereof(Seo.3800 Lab.C.)
Poby No Comp" COUNTY OF LOS ANGELES DEPT OF PUBLIC WOIIKS BUILDING AND SAFETY DIV.
❑ CertlW copy is hereby furnished
BULD
c.rnned copy Is filed with the county building rrapeotlon FOR APPLICANT TO FILL-INS U
' (PRINT Ofl TYPE ONLY)
Data — APPk.n 61
LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT F�
NEAREST
CETTiFICA TE IO
OF DCE)APTN FROM WORKERS' CFlOSS ST.
COMPENSATION INSURANCE A88QRPTION LfNTr 6T 1
(flhls Motion OMd hof be completed hln
the work Invohd by the MAP.BpOK PAGE PARCEL
pwMtt Iy for one hundred dollars($IGO)or{sea.) AIA HANDING UNT CFM Drrncrwo. Pno9NesP er
I oerrfy that In the.performance of'the work for which this permit
Is Issued, I shall not employ any person In shy manner so as to BOILER,BTU
become eubjw to the Worker'Compensation Laws. �17
BTU
ArnivrKe DATE exrrurURB
Dade Appk-d VENTILATION SYSTEM.
NOTICE TO APPLICANT: If, after making this Certlllpate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER p
provisions of the Labor Code, you must forthwith comply with such FIINA-
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED D CONT-RACTORS DECLARATION FLOOR BTU VAUDA710N
I hereby ■fftrm that I am licensed under provision$ of Chapter 9 HEATERSk UNrr
(cgmmenHng with Section 7000) o1 DMelon 3 of the Business and �yALi OQ
Prdfeeetons Code,axed my Iloensg la In full foroe and effect �f
Llcertse Number�"7 Lla Claes /it O
�- ' r
contractor�C Com/ PSK Date — d
❑ I.m sxempt under sac —2 — / Plan,check fee (S
_ B.aP.C.for wa reeaon PERIAAIT ISSUING FEE$ DO 0�—
oe TOTAL FEE DO W
Bstiae d
PLAN CIEO(APPI-r-ANT C0
L
OWNER-BUIDER DECLARATION � Z
f hereby atflrm that I am exempt from the Contractor's License Lew NAME
for the following reason (Section 7031.6, Business and Professlons . , ACCT.It
Code): ADDRESS F7,
❑ F, as-owner o1 the property, or my employees with wages 3307 25.XI
as their sole compensation, will do the work and the CITY TEL NO.
structure is not Intended or otfered for sale (Section 7044, 1 1 I E tJ
Business and Professions Code). OWNER r wl
❑ I, as owner o1 the property, am exclusively contracting TOTAL ��
with licensed contractors to construct the project (Sec- AMDDAESS i �C�i' .G]
tion 7044, Business and Profe"lons Code).
CONSTIO
RUCTN LENDING AGENCY C" / TEL?40. 00
I hereby aftlrm that there Is a constructlon lending ■pency fo —�
I
he pertormance of the work for which this permit Is Issued CONTRACTOR
�-y���y-I �
(Sec.3087,Ctv.C.). IJVSa.-03101 12 fLVf'�O
ADDRESS Du
Lender.r�arrr.
CITY `� TEL-NO.2/.� 2578244b lU 1 Ate 11•moi'
Lenders Address STATE LIC.
I certNy that I have read this application and state that the above LICENSE NO. CLAM
Information Is correct. I agree to comply with all Courtly ordlrtsncee
and State{awe relating to bullding consbuotim,and hereby authortze
repreeentaiivee of this County to enter upon the above-mentioned
property for Inepectlon pu44 SEE REVERSE FOR EXPLAP ATORY LANGUAGE
f