HomeMy Public PortalAbout10244 GREEN ST_Mechanical__ VlORKEIR'S COMPENSATION DECLA ATION 20-004E DPW 9189
I hereby,affirm that I have a certificate of consent to sett Insure,
APPLICATION FOR PERMIT LIME GREEN.
or a certificate
eoof/Worker's MOO LabCompensation Insurnnoa, or a certified � HEATING-VENTILATING -AIR CONDITIONING
f j( u .
Policy f�Ol� a"n'p°r'� COUNTY OF LOS ANGELES' DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Ce Med copy Is hereby fu-rifall d.
cerurted copy Is Mod with the FOR APPLICANT TO FILL IN nADDDR�ES8 / Z q
_ (PRKr OR TYPE ONLY)
Deis D 1� ApplilCantLOCAim
NO. TYPE OF APPLIANCE OR EQUPf1ENT FEE
CFATIF)GATE OF EXEMPTION MOM WOR NEAREST
CRO88 ST.
COMPENSATKNJ INSURANCE ABED PTIpN UNIT BTU ABBESSOR
(This ssatlon need not be oomplaW If the wort Involved by the MAP BOOK PAGE PAFICEL
Permit Is for ions hundred dollars(=100)or leas.} AIR HANDLING urJIr CFM
cenwr na ariocE380)er
I certify 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 BORER,BTU
become suNao.t to the Workers' Compermoon Laws.
COM BTU Armabwua DATe DO-W Q"ayuTUet
Data Appkant VENTILATION SYSTE4
NOTICE TO APPLICANT: If, after making this Certificate of FK)0GR
Exemption,you should become subject to the Workers'Compen&Won Ey,�
provlslons of the Labor Code, you must forthwith comply with such FINAL
provisions Or this permit shall be deemed revoked. RJ VfTY
Llct�sEO TORS DCCLA, T)ON FLOOR S V LIDff#TION
I hereby.affirm that I am Ilc$nsed under provisions of Chapter 9 HEATH UNIT
(co
mms-noing With Soctton 7600)of Division 3 of the Business and WALL
Professions Code,and my license Is In full force and effect.
License N �IS r-L/ / Lla Claes
C." Data
C."
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❑ I am exempt under Sec. Plan Check fee
71
Of
Q.aP.C.forthli reason PERMIT ISSUINQ FFE [ ,
II
TOTALFEE Slgnatre IQ-
CO)OWNER BUILDER DECLARATION PLAN CHECK APPLIC. r
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I hereby affirm that I em exempt from the Contraotof s Boenss Law NAME
for the follow ng reason (Seotlon 7031.6, Business and Professions { 1,
Code): ADDAE88 --yy
❑ I;.es owner of the property, or my employees with wages
as thetT sole.compensation, will do the work and the CITY TEL NO.
struotura Is not Intended or offered for sale (Section 7044,
Buelness end Professions Code). OWPER
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec. AGGRESS 4
tion 7044, Bualno"end Profession Code).
CONSTRUCTION LENDING AGENCY CITY
I hereby affirm that there Is a construction lending agency for ,
the performance of the work for which this permit Is Issued
(Sec.3097,Civ.C.).
ADDF>E38
Lerxiers Name -
. C" TE7-
Lenders Address BTATE LIC.
I certify that I have reed thla application and state that the above i Qz NO. Cr_AS9
In*xTrration Is correct. I agree to oomply with a➢County ordInancoo
and State Tawe g to binding construction,and hereby autfloTbm
la County to enter upon the above-{mentioned
pro for ns on purposea. SFE REVERSE FOR EXPLANATORY LANGUAGE
f� 1