HomeMy Public PortalAbout10121 GREEN ST_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION'
,' FOR hereby affirm that I have a certificate of consent to self F OR PERMIT
Insure, 'or a 4ertificate'af Workers' Gomp*hsWion Irtaurance, - HEATING - VENTILATINe- AIR CONDITIONING
r or'q cettifkd copy thereof (Sec. 3800, Lab. C.) 76A364C
20-0046 DPW 9/86
Rainy No. Company
COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy Is hereby furnished.
❑ Certffl8d copy Is flied-with'the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. C/
(PRINT OR TYPE ONLY) ADDRESS
Date —Applicant- CE LOC,4_ITY
NO. TYPE OF APPLIANOR EQUIPMENT
CERTIFICATE OF EXE PTION FROM WORKERS'' NEAREST
COMPENSATION INSURANCE CROSS ST.
(This section need not be com If the work Invohred by AB504ZPT1oN UNIT, BTU MTRxr nq. BY
the permit Is for one hundred dollars (;100) or less.) /yZZO
I certify that In the perform0
performance of the work for which this A1R HANDLING UNIT, CFM
permft Is Isswed, I shall not employ arty person In any manner
so as to become subject to the Workerrss' CCompensatlloon Laws. BOIL BTU APPROVALS DATE arS SKc� nraE
Dam .._. _-:::E, � ZAppllcantzf
==A ,_ •4t�ii COMPRESSOR, BTU ROUGH
NOTICE TO APPLICANT: If, after making this Certtflcate.of VaMLATION SYSTEM FINAL
Exemption, you should become subject to the Worker'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER V I AT7
with cornI with such provisions or this permit'shall be deem-
ed revoked. FURNACE: FAU V
LICENSED CONTRACTORS DECLARATION FLOOR B
I hereby affirm that I am ilcensed under provisions of Chapter 9 NEAP SUSPENDED UNIT
—
(commbncing with Sectlorr7004)of Division 3 of the Business WALL
and Professions Code,and my Ilcense is In full force and effect.
0 IL
License Number 52 /zIc. Class , O
Con� s�C Dat�(Jp �D O
❑ 1 am exempt under Sec rj
Plan check fee u,
B.BP.C. for this reason CL
PERMIT ISSUING FEE $ Ln
Z
Date:
TOTAL FEE
Signature
OWNER-BUILDER DECLARATION Pb"CHFOC APPLICANT
I hereby affirm that I am exempt from the Contractor's License ,
Law for the following reason (Section 7031.5, Byslness and NAME
Professions Code):
F-1I, as owner of the property, or my employees with ADDRE -
F-1
SS A+CCT.T -
wages as their sole compensation,will do the work and
the structure Is not Intended or offered for sale(Section CTfa 40' M 30.50
7044, Business and Professions Coded OWNER
1, as owner of the property, am exclusively contracting 1 T
TM
❑
with licensed contractors to con4truct the project (Sec- MAIL TOTAL .3
tion 7044, Business and Professions Code). t411 ��
CONSTRUCTION LENDING AGENCY + TEL Q _ cw[rti 30.50
1 hereby affirm that there.ls a tonstructlon lending agency for /
the performance of the work for which this permit It Issued CONTR -00 .
ACTpR ,
(Sec 3097, Civ. C).
ADDRESS
Lender's Name --r.�.W- 12/ 7/89
,E� `�` � 7339 1 Aft 8:05
Lender's Address .
LK—
I cerHfy that I have read this application and state that the Ua�NO CLAM Z
above Informatlon Is correct. I agree to comply with all County _.
ordinances and State laws relating to buildirtg construction,
and hereby authorize representatives of this County to enter
U
t bo meat npd pr rty for Inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
r
Sig a Imnt or Agent Date �s