HomeMy Public PortalAbout4929 HALLOWELL AVE_Mechanical__ DECLARAT
WORKER'S
haveCOMPENSATION
ate of consent to 76A346DPW9,69 APPLICATION FOR PERMIT LIME GREEN
76A364C
- I hereby affirm that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified HEATING -VENTILATING -AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.)
Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN BUILDING
Certified copy is filed with the county building inspection (PRINT OR TYPE ONLY) ADDRESS 2 §L-1
depart ent. /
Date Applicant LOCALITY
PP NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST
RTIFICATE 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
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 j
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
FINAL
provisions of the Labor Code, you must forthwith comply with such .
provisions or this permit shall be deemed.revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION / FLOOR BTU J~ 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. J /
License Number Lic.Class
Poo. CL
_ a
Contractor Date O
s na
I am exempt under Sec. Plan check feeU
B.&P.C.for this reason PERMIT ISSUING FEE $ 3303 _ O
Date: TOTAL FEE fl� i } f"e U
TOTAL x.14 a 15 a
Signature PLAN CHECK APPLICANT (n
OWNER-BUILDER DECLARATION CHECKf},15 z
I hereby affirm that I am exempt from the Contractor's License Law NAME CHANGE
for the following reason (Section 70.31.5, Business and Professions , c•C1YiNGE e;Oft
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, i3I130 0 L1 iie!'!i
i i
Business and Professions Code). OWNER i610 y AN 9a ii%
I, as owner of the property, am exclusively contracting
MAIL
with licensed contractors to construct the project (Sec- ADDRESS -4 I�Z ,-
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TEL.NO. 3
r
I hereby affirm that there is a construction lending agency for CONTRACTOR ,
theperformance of the work for which this permit is issued
(Sec.3097,Civ.C.).
ADDRESS
Lender's Name
CITY TEL.NO.
Lender's Address STATE LIC.
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
representatives of this Court y o enter upon the above-mentioned
propert inspection p ses. SEE REVERSE FOR EXPLANATORY LANGUAGE
9/7
SIGN,4'rk3R OF APPLICANT O AG ATE
,