HomeMy Public PortalAbout5569 HALLOWELL AVE_Mechanical__ ION
DECLARATI
` tm NatR'SCOMPENSATate of consent to 76A346DPWg/89 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 CcApensation 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.
❑ Certified copy is filed with the county building inspection FOR APPLICANT.TO FILL IN gooREBS19�
department. (PRINT OR TYPE ONLY)
Date Applicant LOCALITY �G
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION,FROM WORKERS' NEAREST
CROSS ST. VL.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
Th-is section need not be com leted.if the work involved b the ASSESSOR
(. P Y MAP BOOK PAGE PARCEL
- permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY.
I'certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers' Compensation Laws.
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers' Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU VALIDATION
LICENSED CONTRACTORS DECLARATION FLOOR BTU '
I hereby,affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect.
O
License Number Lic.Class �o
0-
0-
Contractor
Contractor Date 0
I am exempt under Sea Plan Check fee �Q U
B,&P.C.for this reason PERMIT ISSUING FEE$ O.
Date: TOTAL FEE W
Signature a_
PLANCHECK APPLICANT CD
OWNER-BUILDER DECLARATION Z
I hereby affirm that I am exempt from the Contractor's License Law NAME , ^r•i_-'s �s
for the following reason (Section 7031.5, Business and Professions
Code): es a
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. L
structure is not intended•or offered for sale (Section 7044,
Business and Professions Code). OWNER k`HL _t•-�
t3 00
I, as owner of the property, am exclusively contracting MAIL `-j'
_i °-i-'
with licensed contractors to construct the project (Sec- ADDRESS t:".E "
tion 7044, Business and Professions Code). CI
CONSTRUCTION LENDING AGENCY CITY TEL.NO.
I hereby affirm that there is a construction lending agency for CONTRACTOR
the performance of the work for which this permit Is issued
(Sec.3097,Civ. C.). - f i.47,1?'s
ADDRESS _X_f6
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
repreNratatives of this County to enter upon the above-mentioned
prop rt for i pection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATU AP ICA T AGEN DATI IL