HomeMy Public PortalAbout10672 HALLWOOD DR_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89
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I hereby affirm that I have a certificate of.consent to self insure, .
or a certificate of worker's Compensation insurance, or a certified HEATING -VENTILATING-,AIR.dONbITIONING
C py the'reoi(Sec:3800 Lab.C.) ,
Policy No tzmpan Se ff COUNTY OF LOS ANGE!L��' DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished
❑ Certified copy is filed'with the codniy'bui0ing"inspection FOR APPLICANT-TO FILL.IN 'BUILDING
DDDR S Q �d��Gvop,
'department, (PRINT OR TYPE ONLY). �4 � -
Date r _ Gpplican't /'Fr L'. C.� - .. 'LOCALITY
AP /.C ' I� Ij/ .•�/
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE l
10ERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS
COMPENSATION INSURANCE'
ABSORPTION,UNIT,BTU ASSESSOR:
(This section needf not be completed if the work involved b_y the MAP BOOK PAGE. PARCEL ,
permit;is for,one hundred dollars($100)or less.) AIR HANDLING UNIT.,CFM BY
I certify that in the performance of the.work foDISTRICT NO. PROCESSED r which this permit
is issued, I shall,not employ any person In any manner so as to BOILER,BTU "-
ect to the Workers'Compensation Caws:
become subject
R S - INSPECTORS SIGNATURE
COMPRESSOR,BTU - D`
-.
APPROVALS ... : .DATE ..:.-..' G URE
Date. Applicant VENTILATION SYSTEM
"NOTICE-TO-"APPLICANT:`If, after making this„Certificate.of ROUGH
'Exemptioh,you should become subject to.the'Worke�s',Compensation EVAPORATIVE COOLER
provisions of the'Labor Code, you must forthwith comply;with_such _ FINAL
'provislons'oi'this permit shall be-deemed revoked.." FURNACE FAIL) GRAVITY' -
LICENSED CONTRACTORS DECLARATION FLOOR BTU =' D' VALIDATION' ;e
l hereby affirm that.I"am.licensed under provisions of Chapter 9 SUSPENDED -UNIT
(commencing with Section 7000) of Division 3 of the Business and HEATER: .WALL
Professions Code,and my license is in'full force and effect. �
License Number Llc.Class zd
Contractor YY"� �i�Gif���( pate "T•' �3'.—�.� ACCT..& O.
Plan check,fee
❑ �s0
I am' m
exept under Sec. �3.low
B.&P:G.for this'reasoo - 'PERMIT ISSUING FEE$ f0 jTEhlS O
H
Date: r.. TOTAL FEE'. ,. b TI_ITAL W
CL
Signature �+t� i r�
PLAN CHECK APPLICANT CASH .n�y7,3.10 5
OWNER-BUILDER DECLARATION` ` z
I hereby,affirm that I am exempt from the"Contractor's'License Law NAME CHANGE*,. v0
0 7
for the following reason(Section 7031.5, Business and'Professions
Code) - - ADDRESS'... _ -
❑ I aSiowner of the property, or my employees with wagesZ) 4/23/96
as their sole compensation, will do the work and the CITY .TELTJO: Fi• [n ,3 i ,thin i
structure is not intended,or offered for sale (Section 7044, 6070 1 AN10-'21
'Business and Professions Code). ,OWNER
I as,owner of the property, am exclusively contracting MAIL
with-licensed contractors tocon strucYthe project (Sec- - ADDRESS{ � .�•-- -'
tion'7044; Business and Professions Code).
CONSTRUCTION,LENDING AGENCY CITY ' Ski 1/0j TEL:NO.
I Hereby affirm that there is a construction lending agency for CONTRACTOR v�, 6
the performance of the work for which this permit.is issued / G� �' G�� e n• .•
(Sec.3097,Civ. C.).
ADDRESS
Lender s"Name /► .�J Q
CITY. H TEL.NOf
-Lender's AddressSTATE / LIC.
I?certrfy'that I'have read this application and state.that the above LICENSE NO. CLASS
infoemation is correct. Lagree to comply with all County ordinances
and State laws relating to building conWuction',and hereby"authorize
,representative.s.of this County,to enter upon the.,above-mentioned
proper for inspection purp es. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APPLICANT OR AGENT - DATE