HomeMy Public PortalAbout5524 HALLOWELL AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9,89 APPLICATION ,FOR.PERMIT
76A364C .LI�AEp' GREEN
I hereby'atflrm that I have a certificate of'consent to self Insure,
or 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
Certrfied copy is filed with the count tiuildin' Ins action FOR APPLICANT TO FILL IN BUILDINGC 1�
r department . y - g p Y (PRINT OR TYPE ONLY) ADDRESS
L c� a r
DateI 7 '! Applicant.�r -v� �.���e— LOCALITY. G cb
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS ST ,
COMPENSATION INSURANCE, ABSORPTION UNIT,BTU
(This section: not be completed if the work, b the ASSESSOR
( P Y MAP BOOK PAGE- PARCEL,—
permit Islor one hundred dollars($100)or.,less.) AIR HAIJDLING UNIT,CFM -
, - DISTRICT NO r PROCESSED BY
^
certify,that in the performance of the work,for which this permit •:. *r a.
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers' Compensation Laws: �;f
' COMPRESSOR,BTU
�' p•-. ' - APPROVALS .DATE INSPECTOR'S 91.4.11'El. _
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„youmust forthwith comply with such FINAL
,-,provisions or this permit shall,be deemed revoked. FURNACE FAU' TY,"-
LICENSED
Y, '-LICENSED CONTRACTORS DECLARATION / FLOOR ' BTU B Q VALID_ ATION•- �c”
I hereby affirm,that.l am licensed under proy,isions of Chapter 9 HEATER SUSPENDED UNIT—
(Commencing
NIT _ y
(Commencing with Section_7000) of Divlslon_3 of the Business and = WALL"
Professions Code, and my license is in full force and,effect
License Numb Llc'Class
Contra t^ Date 0
❑ Plan check fee. i U
am exempt under•Sec. _
B.BP.C.for this reason PERMIT ISSUING FEE $ 3 io
Date: TOTAL FEE 00 - U
P tL
Signature ; __. 4 L ."• n.
PLAN'CHECK APPLICANT (n
OWNER-BUILDER DECLARATION
_Z
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T.
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hereby affirm that I am.exempt from the Contractor's.License Law NAME -7 '
for the following reason (Section 7031.5, Business and Professions Z� ,'=F __ +_I+ :t •SII-f
Code). ADDRESS.• L�-� .. ., •f T r , >
❑_ I,•as owner of the property, or my employees with wages "��"o� �� 1;ITE"! 'tj
as their sole compensation, will do the work and the CI TEL.NO. j 7�3 ,TC)'�'AL . ' .57x•00
structure Is not intended or offered for=sale (Section 7044, i `
Business and Professions Code) OWNER❑ i.HE ,p;: ' ,57 o1��•'•.,., ;
,.I,•as owner.,of the property, am exclusively contracting r
with licensed contractors to construct the project (Sec- ADDRESS�r�� 2 CH It
,i(f!'',
tion 7044, Business and Professions Code). q
CITY' TEL NO Z
CONSTRUCTION LENDING AGENCY. = '
I hereby:affirm that there is a construction lending agency for I]I 0'}'IJt_I�ll _tAt_P t
the performance of•the work for which this permit Is issued CONTRACTOR -
(Sec:-3097,Civ.C.). , ' -
irll 1 rlr
°tr'?
•-`' _ ADDRESS /') - - '".•
Lender's Name
CITY TEL. t.
Lender's Address STATE 77 LIC. -
I certify that I have read this application and state that the above LICENSE NOL CLASS. CZo.• : 3 y •r:-
information is correct. I agree to comply with all County ordinances
and State laws-relating to building construction,and hereby authorize rt'
representatives of this County to enter upon the above-mentioned
proper f r in ectio pyrposes. SEE REVERSE FOR EXPLANATORY LANGUAGE,,
1y�Si RE OF APPLICANT OR AGENT DATE , '