HomeMy Public PortalAbout4902 HALLOWELL AVE_Mechanical__ WORKER'S COMPENSATION
certificate
of DECLARATION 76A346Df'W9,89 APPLICATION FOR PERMIT LIME GREEN.
76A364C
I hereby affirm.that I have a certificate of corisent to self insure,
or a certificate of worker's Compensation suran e; a certifi M4HEATII�IG.-VENTILATING -AIR CONDITIONING
copy thereof Sec.3800 Lab. �CCm."
Policy NM-2*' /P-2-1Cbmpany COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
Certified copy is filed with the county bu' g i ec FOR.APPLICANT TO FILL IN �BUILDINS
depar:7-1t t. (PRINT OR TYPE ONLY)
Date Applican NO. TYPE OF APPLIANCE OR EQUIPMENT FEE07
LOCALITY
CERTIFICATE OF EX PTIO FROM WORKERS' NEAREST
CROSS ST. A -21 051
COMPEN TIO /FROM
ABSORPTION UNIT,BTU
(This section need not be completed if the work involved by the ASSESSOR
AP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.). AIR HANDLING.UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify,that in the performance of the work for which.this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU a
become subject to the Workers' Compensation Laws. Q O
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO'APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU Y
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
hereby affirm that.I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and WALL _
Professions Code, and my license is in full force and effect.
License Number �v Lia Class
Cond ate 6/5/h
R
ti o
❑tract I exempt under Sec. Plan Check fee TOTAL
® V
B.&P.C.for this reason PERMIT ISSUING FEE$ & 7 b "HE s�+.4 0
Date: iy 1��i�•G ,i )� U
TOTAL FEE �Q. �D W
Signature _ 0-
PLAN CHECK APPLICANT - q -7 -t; (A
OWNER-BUILDER DECLARATION R_I_I3ItE— I�{ y ��fl r?: Z
I hereby affirm that I am exempt from the Contractor's License Law NAME , ;ii iI 1'+°'
for the following reason (Section 7031.5, Business and Professions
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
with licensed contractors to construct the project (Sec- ADDRESS 2
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CIT TEL.NO. "
I hereby affirm that there is a construction lending agency for CONTRACT
the performance of the work for which this permit Is issued
(Sec. 3097,Civ. C.). _... ., _ .. ..._. .. _. . _ -
ADDRESSrf
Lender's Name
TEL.NO. _
Lender's'AddressSTATE LIC. of --
I certify that I have read this application and state that the above LICENSE NO. CLASS ^
information is correct. I agree.to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
representatinter upon the above-m phone
r . .
p / SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATU OF" DAT