HomeMy Public PortalAbout5542 HALLOWELL AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 200046 DPW 9/89 A'PP'�_ICATION FOR PERMIT
,76A364C - tIME*-:' GREEN ,
or
II hereby affirm'that I have a certificate of consent to self Insure;'a certificate of Worker's Compensation Insurance, or a.certified I EATIIG -VENTILATING -AIR CONDITIONING •
copy thereof(Sec.'3800 Lab.C.) D' , { 9
' Policy No Company(��l�I�e Q1�1Y1y 'COUNTY OF LOS ANGELES DEPT OF-PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished. ��l/
❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN ADDRE S
-department. (PRINT OR TYPE ONLY)'
Date Applicant , I LOCALITY �m Cp /. •- -
NO.• TYPE OF�APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF,•EXEMPTION FROM WORKERS' ' NEAREST Gl1le
CROSS ST
COMPENSATION INSURANCE ABSORPTION UNIT,BTU '
(This sectioA need not be•completed If the work Involved,by the ASSESSOR
`' MAP BOOK, PAGE 'PARCEL' -
permit Is for one,hundred dollars($100)or less.)" AIR HANDLING UNIT,CFM o •
DISTRICT NO PROCESSED BY ,
I certify that in the performance of the work for'which.thls permit- -
is issued, I Shall,not employ any person in any manner so as to BOILER,BTU
become•subject to tfie"•Workers' Compensation,Laws' rC==
COMPRESSOR,BTU
Date Applicant APPROVALS ,. DATE INSPECTOR'S SIGNATURE'
- ' VENTILATION SYSTEM `
NOTICE TO APPLICANT: If; after making.this Certificate of ROUGH
Exemption,you should become subject to the Workers' Compensation EVAPORATIVE COOLER
provisions of'the Labor'Code, you must forthwith comply with such' FINAL _
provisions 6r this-per'mlt shall be�deemed revoked.• FURNACE. FAU GRAVITY o
„i' •pA,-' '
-LICENSED CONTRACTORS DECLARATION, / FLOOR BTU 6 . ' VALIDATION?
l heieby'affirm that I art 'licensed under,provisions.of,Chapter 9 SUSPENDED UNIT T
(commencing with Section 7000) of Division 3 of the Business and HEATER SWALL
USP ' t-j!:�•1 .a
"'P,ofessions Codd, and my license is in'full force and effect.
307 ;. 71. 5 .
. . //•1 i TTTCf�
License Number�s82 a Lic.Class � � �� } or-J41 ;1 I C1
TOTAL `.-a 1® 25.,a
Contractor / . Date �~ ���� 1 ,rte Q
❑ I am exempt under ;Sec . Plan Check•fee ;CHEC }1 i`-I U
B BP.C.for this reason '' PERMIT ISSUING FEE$ �•H�i 7� .� 1 0
Date Z — 2_C TOTAL.FEE
22-22
rr. W
Signatur IJI�Q�-I 1 11I x!19`?.a
?
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT, —
Ail 9,51 Z_
Thereby affirm that I am exempt from the Contractor's License Law _ ,NAME
for the following reason (Sect to n'7031.5,1 Business and'Professions
Code)-
ADDRESS
"I,as owner of the-property, or my employees witti'wages
'as their sole'compensation, will do,the work and the CITY TEL NO
structure'is'not intended-or offered for sale (Secuori 7044, ,Ia
Business and Professions-Code) OWNER
as � '
❑ y
I, owner of the property; am,exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code). a
';CONSTRUCTION LENDING'AGENCYt CITY, TEL.NO
hereby affirm that there is a construction lending agency.forCONTRACTOR., °'w
the performance of the.work-for which-this permit Is Issued
(Sec. 3097; Civ.C.) 2
ADDRESS 61- .
Lerider's Name y/f r, I-/ ( ON .
CITY i /�(/ V I .TE .NO:
Lender's Address STATE gf�- LIC
B; 25
'Certify that I have read this application and state that the above' LICENSE NO � CLASS C ... ,.. •• '
information Is correct. I agree to comply with all County ordinances
and State laws'relating fo building construction;and hereby authorize • i '
representatives of this County to enter upon the above-mentioned
property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE- "
SIGNATURE OF APPLICANT OR AGENT DATE - r