HomeMy Public PortalAbout5619 HALLOWELL AVE_Mechanical__ WORKER'S COMPENSAT:ION DECLARATION j6A364C .
0-0046 PW 9/89 APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self-insure, 1
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or a certificate of Worker's-Compensation Insurance, or-a certified Y
copy thereof(Sec.3800 Lab.C.) HEATING -VENTILATING-AIR CONDITIONING''
Policy No. Company COUNTY OF LOS ANGELES - DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
El -Certified copy is filed with ttpounty building inspection. FOR APPLICANT TO FILL IN BUILDING. •?�'.
department. (PRINT OR TYPE ONLY) ADDRESS
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Date ApplicantLOCALITY
,. NO. TYPE OF APPLIANCE OR EQUIPMENT FEE _
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
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($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as.toBOILER;BTU k
become subject to the Workers' Compensation Laws. t -j /` ''i.`•�y .i`-
COMPRESSOR,BTU "�f �' 2'' t r. '"?
+') - APPROVALS � DATE INSPECTOR'S SIGNATURE
Date/ — �� �� Applicant -��� 5 y � �� VENTILATION SYSTEM
NOTICE fO APPLICANT: If, after making this Certificate of ROUGH
Exemption,-you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the'Labor Code,.you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. fFLIRNACE: FAU - GRAVITY
LICENSED CONTRACTORS DECLARATION ./'f-'`G FLOOR BTU--;;",.-2 = VALIDATION
I hereby affirm that Iam licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the-Business and HEATER: WALL
Professions Code,and my license is in full force and effect. �•-+, *-
. License Number Lia Class - -
Contractor A -/ r' Date
❑ Plan check fee
I am exempt under Sec. LU
B.&P.C.for this reason PERMIT ISSUING FEE'$ :.•.i" LJ.
Date: •TOTAL FEE, . >_
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
1 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 - .. r 3..1r i r iC
LLI
❑ I, as owner'of the property, or.my employees with wages �; "«
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as their sole compensation, will clothe ,work and the CITY TEL.NO.
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structure.is not intended or offered'for.sale (Section 7044, r . .
Business and Professions Code). OWNER l
❑, I, as owner of the property,am exclusively contracting
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with licensed contractors to construct the project,(Sec- ADDRESS
tion 7044,'Business and Professions Code);
CONSTRUCTION LENDING AGENCY CITY ,r Nye N f;J f, TEL.NO. rI f^
1 hereby affirm that there is a construction lending agency for
the performance of the work'for which this permit Is issued CONTRACTOR
(Sec.3097,Civ.04 ,• ff ,
h ADDRESS / ` / r ✓ I f 4 , SX Q I
Lender's Name r r w Alt',
CITY v /+f r+ �EL.NO
Lender's Address 5 APSE ' v LIC.
I certify-that I have read this application and state that the above L2EME NO. ,l,, f - �, 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 County to enter upon the above-mentioned
property.for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
'•'�S,§L ATURE70F APPLICANT OR AGENT + -`T DATE