HomeMy Public PortalAbout5252 HALLOWELL AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 2MD46 DPW 9/89APPLICATION FOR PERMIT
I;}•2reby,a i,.wn Ahat I have a certificate of consent to self insure, 76A364C
or a certificate of!Worker's Compensation Insurance, or a certified HEATING -VENTILATING -AIR NDITIONING
copy t�h�e�re�/ ( c 3800 Lab.C.) CO
Poli 0. Company COUNTY OF-LOS ANGELES DEPT OF PUBLIC WORKS c BUILDING AND SAFETY DIV.'
❑ Certified copy is hereby furnished
Certified copy is filed•with the county building'inspection' ` FOR APPLICANT TO FILL IN ' ADDRESS
d art ent. (PRINT OR TYPE ONLY) C�� ✓`�./
'APPOcant LOCALITY
NO.' TYPE OF APPLIANCE OR EQUIPMENT FEE'
' CERTIFICATE OF,EXEMPTION FROM WORKERSNEAREST
'
- CROSS ST ,
COMPENSATION INSURANCE :, 'ABSORPTION UNIT BTU ASSESSOR
(This.sectlon need not.be completed If-the work,Involved by theMAP BOOK PAGE .PARCEL
permit,is for one hundred dollars($100)or less.) AIR-HANDLING UNIT,CFM
DISTRICT NO PROCESSED BY' .- y�•,.. r• -
I certify that in-the performance'of the,work foi which this permit
l ,
is'issued, I•shall'not employ any personn„any manner so as to BOILER;BTU '' n
become-subject to the Workers' Compensation Laws - e
COMPRESSOR,BTU • 0
Date- ' A hcant APPROVALS, - DATE INSPECTOR'SS16NATURE
PP VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
YEzemption,you should become subject to the,Workers'Compensation.
EVAPORATIVE COOLER' FINAL
-,provisions of the Labor;Code,you must forthwith comply with such.
provisions or this permit shall be deemed revoked. FURNACE• - FAU GRAVITY +
LICENSED'CONTRACTORS DECLARATION' FLOOR BTU VALIDATION
I hereby affiFm that I'am licensed under provisions`of Chapter'9 SUSPENDED UNIT
(commencing with Section 7000) of Division 3-of the Business and HEATER WALL
Professions Code,'and my'license is In full force.and effects
License,Number Llc:Cloil.ass
'ti. }
Contractor liate 0
❑. ram exempt under sec Plan check fee V
B.&P.C.for this reason
PERMIT'ISSUING FEE.$. '0
Date: TOTAL FEE W
Signature _ a
'PIfAN CHECK APPLICANT _ - U)
'OWNER-BUILDER DECLARATION'' - Z
I hereby affirm that`I am-exempt from,the Contractor's License Law' NAME
for,the following reason•'(Section 7031.5, Business and Professions.
Code): ADDRESS.
I, as owner of the property; or my employees with wages. --7
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 t p �—kd—�
❑ 1,,as owner.of the property, am exclusively contracting MAIL �/ Y t I-t I HL
a m a—P�P '.
with licensed contractors to construct the project (Sec- ADDRESS '
tf
tion 7044, Business and Professions Code) , - (-HtL
CONSTRUCTION LENDING AGENCY ' CITY TEL.NO €•Flt��if7� aI Iij
4.1 hereby affirm that there is a construction lending agency for
uCONTRACTOR ' i!
the performance of the work for which this permit Is issed
(Sec. 3097, Civ.C.). _ ,. w _ fy i ”
ADDRESS IIII I—„I IUI 5i'`A?1, "
Lender's Name
_ CITY TEL.NO. -1 L•i 1 i=1iI i 1
•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 authonie '
represent sof this County to enter upon the above-mentioned -
prope or do pu po es: SEE REVERSE FOR EXPLANATORY LANGUAGE
N ;
SIGNATURE OFAP CA R AGENT DA .r - •' � - 'vr� '