HomeMy Public PortalAbout4952 GLICKMAN AVE_Mechanical__ WORKER• PENSATION DECLARATION 20-0046 DPW 9/89 or`
76A364C AIWICATION FOR PERMIT LIME GREED
I hereby affirm that 1W a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified HEATING -VENTILATING -AIR CONDITIONING
cgp�I�ereo����09 Lab. C.)
Policy No. - Company � 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 ���
departure t. �1 (PRINT OR TYPE ONLY) ADDRESS fi�G bC jty�.� ✓� ,
Date Applicant i s � l�"�� LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSSSST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
This section need not be completed if the work involved ASSESSOR
( b P Y the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers' Compensation Laws.
COMPRESSOR,BTU gor.L® ®dam
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption, you should become subject to the Workers'CompensationEVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL 6'a 9
provisions or this permit shall be deemed revoked. , FURNACE: FAU MII YIW VALIDATION
LICENSED CONTRACTORS DECLARATION FLOOR -BTU
_ 1
hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code, and31 m5y licee/'S c•
nse is in full force and effect. �l0 JAIL �Gr•rL�_r
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License Number Lic.Class !'
IL
IL
Contractor 21e
❑ I am exempt under Sec. Plan Check fee -
B.&P.C.for this reason PERMIT ISSUING FEE$ i sf
Date: TOTAL FEE
UJ
Signature
PLAN CHECK APPLICANT
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law NAME ���N�N1��e__
for the following reason (Section 7031.5, Business and Professions - J
Code): ADDRESSe -
❑ 1, as owner of the property, or my employees with wages
�Z� ' ZGl��� -
as their sole compensation, will do the work and the CITY &, e-AA L��g7pGTEL.NO. g'7sE-=77
structure is not intended or offered for sale (Section 7044,
Business and Professions Code). OWNER !r T� r3; /a-/1ER_IVA7/0orA L_
❑ I, as owner of the property, am exclusively contracting MAIL y L-_
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY o� 47 c9,9 TEL.NO.
��
I hereby affirm that there is a construction lending agency for CONTRACTOR o
the performance of the work for which this permit Is issued
(Sec.3097, Civ.C.).
ADDRESS
Lender's Name
CITY AA e—H A/ TEL.NO. 57 72 -
Lender's Address STATE ._ LIC.
69M ��
I certify that I have read this application and state that the above LICENSE NO. CLASS p
information is correct. I agree to comply with all County ordinances PJ ,
and State laws rela'ng to building construction,and hereby authorize
representative his C unty to enter upon the above-mentioned
property for n ctio �urpose� SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE PPLICANT R AGENT DTE