HomeMy Public PortalAbout10221 GREEN ST_Mechanical__r
ASPRKM'S COMPENSATION DECLARATION 20-W4-8 DPW 9 f ea APPLICATION FOR PERMIT
I heg&Sy afl�4that I have a oertiflcate of consent to self Insure, 7BA�e4C
or certlpha
.;rat
ere Compensation Insuranoe, or a oertlfted r N HEATING-VENTILATING -AIR CONDITIONING
copy 4iareof(Seo.3800 lab.C.)
0 No• company COUNTXOF LOS ANGELES DEPT OF PUBLJC WORKS BUILDING AND SAFETY DIV.
Cerdfled copy is hereby hrmilahed.
❑ FOR APPUCANT TO FILL IN O
centrad copy h flied with the oourrty bufkitrig Irepecifon
L (PFIINT OR TYPE ONLY)
Dee Ate" NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LocAL" mr4
CERT1F1CATE OF EXEMPTION FROM WORKERS'. NEAREST r ` � ` /r'i �W
rh y �
COMPENSATION INSUINSURANCEA89ES OR C (Sp !
ABSORPTION UNIT,BTU
(fhb section need not be comp&&W if the work Invotved by the NAP S qLS PAGE PAFKXI/ .
permit La tof one hundred doffars(SIGO)or f.aeJ AIA FWM4JNG UNrr,CAA
orTrecrro. er
I oerttfy that In the performance of the work for which this permit
Is Issued, I shall not employ any parson In any manner so as to BTU
become subject to the Worker' Compenaallon laws.
BTU
APmovAu nATa PON-00TOR'e SMATNE
Data Appk-Tt VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of FIOl173H
Exemption,you should beoo-me sub)ect to the Workers' Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith oomply with Ouch FNAL Z.`is
provision or this permft shall be deemed revoked. FLIRNACF-* FAU GRAVITY
IJC:N CONTRACTORS DECLARATION FLOOR BTU VALDATION
I hereby affirm that I ■m licensed under provisions of Chapter 9 HEATEFL SUSPERDM UNIT L
(commencing with Section 7000) of Dlvialon 3 of the Business and W h
Profeesions Code,and my Ilcense Is In full force and affect. l ,4�.T
Lkx vq Number LkL CLe"
oil. t rTEr
Contraotor Date TOTAL 34 - 958
❑ I am exempt under Seo. Plan Check fee .HED', i.'4.Ojs Q
B.sP.C.for tHa reason PERMIT ISSUING FCE$ .11113�
ITOTAL FEE L��yI 0 0�{, 1 ' f IL
LU
� Drs PLM CHECK APPLICANT I. I
OWNER-BUILDER DECLARATION �� J i 1 AM '8,4 —
I hereby aH1rm that L am exempt from the Contractor's License Law NAME
fcr the following reeaon (8e70ealons
ction 31.5. Business and Profe pool
Code): ADDRESS
❑ 1, as owner of the property, or my employees wl)Il Wages
as Ihelr sole compensation, will do the work and the CITY TEL-NO.
structure Is not Intended or offered for sale (Election 7044,
'Business and Professions Coda). y
rn r
�J I, as owner of the property, em exclusively contracting /45
with licensed contractors to construct the project (Seo- ADDRESS it '� (y -MAI-LS
tion 7044, Buslneee and Profeealons Code). ,gyp
CONSTRUCTION LENDM AGENCY CITY � I '^12-
TEL � �x OC-�►
Ihereby affirm that there Is a construction lending •pency for AOR ,
the performance of the work for which this permit le Issued
(Sea.3097,Ctv.C.).
ADDRESS
Lenders Name
CITY TIB_NO.
Lenders Address STATE LIC.
I certHy that I have read this applloatl)n and elate thAt the above LICENSE NO. CLASS
Informerioo la correct. I agree to comply with all County ordinances
and State inure relating to burkFing construction,end bereby authortre
reprseentaffvee of this County to enter upon the above-mentioned
property for n op pu gff REVERSE FOR EXPLANATORY LANGUAGE
TE