HomeMy Public PortalAbout4816 HALLOWELL AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT
I herebkaffirm that I have a certificate of consent to self
insure; or a certificate of Workers' Corrloensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
ora certified copy thereof (Sec. 3800, Lab. C.) 76A364C
20-0046 DPW 9/88
Policy No.—Company—Ick-0 Y
❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. ADD
(PRINT OR TYPE ONLY) RE S.5 0(N
tn� ry
Date Applicant �J �'� , ,Gj 1 LOCALITY I
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. O SSED BY
OC�
the permit is for one hundred dollars ($100) or less.)I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM
permit is issued, I shall not employ any person in any manner
so cis-to become subject to the Workers'Compensation Laws. BOILER, BTU APPROVALS DATE INSPECTOR'S SIGNATURE
Date. Applicant COMPRESSOR, BTU ROUGH
NOTICE TO APPLICANT: If, after'making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers' e
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATIO
with comply with such provisions or,this permit shall be deem-
ed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU 00
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business WALL.
and Professions Code,and my license is in full force and effect.
.. d
License Number Lic. Class , O
V
Contractor Date
❑ I am exempt under Sec. 0
Plan check fee V
W
B.&P.C. for this reason. H
Date: PERMIT ISSUING FEE $ Z
Signature TOTAL FEE c�o 150
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License ,
Law for the following reason (Section 7031.5, Business and NAME
Professions Code): -
I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation, will do the work and
CITY TEL. NO. -�30-g 20 50
the structure is not intended or offered for sale.(Section ,.�Ls ;. ..c.n•J-
7044, Business and Professions Code).
❑ I, as owner of the property, am exclusively contracting OWNER f ITEMS
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS TOTAL OI AL 20-.50
CONSTRUCTION LENDING AGENCYCITY TEL. NO. 'vitiCe•Il il. .5011
I hereby affirm that there is a construction lending agency for t.,�
the performance of the work for which this permit is issued CONTRACTOR , w.HrAGGE �LI�I
(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name :;
CITY TEL. NO. 01010101-1130131 111��:��,4
Lender's Address I RM 3:26
I certifythat I have read this application and state that the STATE LIC. -
PP LICENSE NO. CLASS
above information is correct. I agree to comply with all County
ordinances and State laws relating.to building construction,
and hereby authorize representatives of this County to enter
on the above-mentio d�7p rty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of App cant or Agent Date 95