HomeMy Public PortalAbout4836 HALLOWELL AVE_Mechanical__ ' V'vORKER'SCOMPENSATION DECLARATION 76A364C PW 9,89 0-0046
APPLICATION FOR PERMIT LIME GREEN
I heroby affirm that I have a certificate of consent to self insure,
or a certificatewf Worker's Compensation Insurance, or a certified HEATING:-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab. C.)
t N b, et
Policy No. Company ee6:6g� t.COUNTY OF LOS ANGELES bEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
��Cerfified
ertified copy is hereby furnished.
BUILDIcopy is filed with the county building inspection FOR APPLICANT TO FILL IN ADDRESS /
department. (PRINT OR TYPE ONLY) ADDRESS
Date I Z "S� Applicant s Lca�=i 4• g'1�• LOCALITY .G +
�—r NO. TYPE OF APPLIANCE OR EQUIPMENT, FEE
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
ASSESSOR
(This section need not be completed if the work involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
D
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU
-. APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. / FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION ( FLOOR BTU 155 to VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL
Professions Code, and my license is in full force and effect.
int_ t•T
License Number S�dIS� Lic.Class
Contractorl� -� -+ SyT Date --•�
❑ i am exempt under Sec. Plan Check fee j s f'A 106 � IL.: E P
B.&P.C.for this reason PERMIT ISSUING FEE F`., ='-f='n= O
Date: TOTAL FEE
Signature d
PLAN CHECK APPLICANT,
OWNER-BUILDER DECLARATION I I_IY`^', f�i5='' Sstr'A-` `:� Z_
I hereby affirm that I.am exempt from the Contractor's License Law NAME ,_ _� _; :-;,'I-;I3
for the following reason (Section 7031.5, Business and Professions ► _1• =
Code): ADDRESS
❑ I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale (Section 7044,
Business and Professions Code). OWNER
❑ I, as owner of the property, am exclusively contracting MAIL ' t
with licensed contractors to construct the project (Sec ADDRESS .4S
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TEL.NO.
.�'
I hereby affirm that there is a construction lending agency for CONTRACTOR '
the performance of the work for which this permit Is issued �j
(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name
CITYTEL.NO.q,
i
Lender's Address STATE I LIC.
I certify that I have read this application and state that the above LICENSE NO. Sso 5[p CLASS 20
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 upon the above-mentioned
property for inspection urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APPLICANT R AGENT - DATE