HomeMy Public PortalAbout10014 GREEN ST_Mechanical__ WORKER'S COMPENSATION° "'°" DPI"
ereAPPLICATION FOR PERMIT L�RE GREEN
I hbratflrrn that I have a cartiflcatq o1 consent to self Insure;
or a oertifionte o1 Worker's Corrpeneatlon Insurance, or a certifled HEATING-VENTILATING-AIR CONDITIONING
oopy thereof(Seo.3800 Lab.C.) g —
No. r3� ry - �'`r �7JND COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
CerttM1ed copy Is hereby fur hOwd.
❑ Certlfted copy Is Ned with the qty b,dkhrQ tr,epeotkx, FOR APPLICANT TO FILL IN
deparhnenL (PRINT OR TYPE ONLY)
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LOCALITY
Date ,Appticnrtt =� NO. TYPE OF APPLIANCE OR EQUIPMENT FSE
NEST
CERTIFICATE OF EXEMPTION FROM WOFNEIQ ' CRM ST.
COMPENSATION INSURANCE ABBDRPTYON UNIT BTUBO
(Thls seotlon need not be oompleted H the work Involved by the MAP BOOOKK �,j a� PA3E PAHca,/.�d
permft to for one hundred dolls»(8100)or Is".) ALA HANDLING UNIT CAI oWFracrNo. rnocrBMer
I oe"that In the performance o1 the work for which this permit
Is Issued, I shall not employ any person In any manner so as to BOCLEFI,BTU �O O
become subject to the Workers'Compensation Laws. O `
BTU /,On A0,10
rrpnoraa sire eOVaorure eomTure
Date AppillCerR VENTILATION 8YSTENI
NOTICE TO APPLICANT: If, after making this Certificate of FIOOGH
Exemption,you should become subject to the Worker'Compensa loh EVAPORATIVE COOLER FINAL
provisions of the Labor Code, yo4 must torthwfth comply with such
provlatons or this pwmtt shall be deemed revoked. FURNACE: FAU
LICENSED ORS DECLARAITON FLOORBTU 002d V I A ION
I hereby affirm that I am licensed under provisions of Chapter 8 HEATER: 8USPENDED UNIT
(commencing With Section 7000) of Division 3 of the Business and WALL
Professions Code,and my license is In full force and affect
Lkenas Number IOU Ur-Gees
v
Contractor qn)C AI Det. AC C:T.A
❑ I am exempt under Sea Plan Check fee
B BP.C.for the reason PERMIT ISSUING FEE 1 ITEM 11ITEMw
�, TOTAL FEE TOTAL 119 - !1
s�n�rp a
OWN ILi6 DECLAAAT1bN MAN CHECK APPIx wr C�$CK 117.•`_� Z
I herby affirm that I am exempt from the Contraotore Uoense Law KkWE i+�y N�rJG-� �fi �� , ry rn�� ��
for the following reason (Seotlon 7031.6, Business and Prafeealons cw I^+ bey CUMTE
❑
Code): ADDS1Y. 57
35-
I, as owner of the property, or my employees with wages ^t�;lvt
ao their sole compensation, will do the work and the CLTY f7 TEL NO 0000—WI O �Y/ O/
structure la not Intended or offered for sale (Section 7044, 10x1 1 AtIiQ%3
Business and Profeeabns Code). OWNER
❑ I, es owner of the property, am exclusively contracting MALL
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Bualness and ProfeeWk"Code).
CONSTRUCTION LENDING AGENCY Cf T1 TEL NO.
I hereby affirm that there le a construction lending apenoy for dam)
the pertormanoe of the work for which this permit le Issued TOR i/I/V CO
(Seo.3077,Ctv.C.). -
ADt>FtESS
Lenders Name
CtTY -r tX TEL No-7
Lenders Add rase STATE LIC.
I oertNy that I have read this application and state that the above LICENSE NO. CLASS
Information Is correoL I agree to oompfy with all County ordlnanoes
and State laws relaffiIg to bulking construcdon,and hereby authort m
repreeentatfvee of this County to enter upon the above--mentioned
property r Inspectlon purpoaee. SEE pEyEFtSE FOR EXPLANATORY LANGUAGE
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MEW DATr