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HomeMy Public PortalAbout5508 HARKER AVE_Mechanical__ • 20-0046 D .; .. _. WORKER'S COMPENSATION.DECLARATION 20-00 4C PW 9/6976A3 ,� y� I_ ereby affirm that I have a'certificate of consent to self insure, �U- ,'� �'j� l or,a certificate of'Worker's Compensation Insurance, or a certifiedHEATING-•VENT,ILATING -AIR CONDITIONING r copy thereof(Sec.3800 Lab. C.)_ Policy+No. �a J� l Company� `+i `� COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS ��BUILDIN_ G AND SAFETY DIV._- :.; Certified copy is hereby furnished. .. FOR APPLICANT TO FILL. .BUILDING ; ❑ Certified copy is filed with the county building inspection ADDRESS v© . IP/r .-Ave,-- dep menta (PRINT OR TYPE ONLY LOCALITY. Date `r APPlicant (//h (�rGZ '" �lh, • Q e� NO. TYPE OF APPLIANCE OR EQUIPMENT •FEE ' I NEAREST (�� CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. 2{. 4h1'' - rrv '• COMPENSATIOWINSURANCE ABSORPTION UNIT,BTU' ASS" SSOR (This section,need not be completed if thework involved by the MAP EBOOK PAGE PARCEL permit„is'for one hundreiJ'dollars($100)ocless.) - AIR'HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY , I certify that in the performance of the,work.for which this permit , is'issued; I shall not employ any person,in any'Manner so as toa BOILER,BTU .become subject to the Workers'Compensation LawsQ� COMPRESSOR,BTU T '61 <' .. APPROVALS DATE.: INSPECTOR'S SIGNATURE Date Applicant - „` _ •. _VENTILATION SYSTEM - .NOTICE TO APP.LICAN,T: .lf; after"making this Certificate of ROUGH � Exemption,you should become subject to the Workers Compensation EVAPORATIVE,COOLER provisions'of.'the Lkoi'-Code,'you must forthwith comply with such FINAL provisions or(his•permit,shall be deemed revoked. FURNACE FAU V GRAVITY " LICENSED CONTRACTORS,DECLARATION FLOOR ti''' BTU` VA ATION 1'.hereby affirm that,l am licensed under provisions of Chapter 9 SUSPENDED'' UNIT i HEATER: (commencing with Section 7000) of Division 3 of.the Business and. WALL : ✓� J'. Professions Code,'and'my license is'in full force.and effect License Number Lic ClassAn i , �V r 6I r 3: Contractor "fY 1 UO Lr>lff Date - t TO l� V Plan check fee _ ❑.. 1,am exempt.u'ndersec. F' tT .� B.&P.C.for this-reason PERMIT•ISSUING FEE$ r(� �' I - • - _- ,�/ �.HE lir �.V Date: TOTAL FEE I• / ::iI.c o>=l.j a Signature, PLANCHECKAPPLICANT Z OWNER-BUILDER DECLARATION _ I hereby.affirm that I,am exempt from'tha Contractor's License Law NAME !I_f l ) I� # �j j4 �F forthe:following reason (Section 7031.5 Business and Professions _ D Code): ADDRESS. 3 I� 1, as owner of the property, or my,employees with wages. as their sole compensation, will do the-work and the CITY TEL.NO: ;,r structure is hot intended or offered for sale (Section 7044, Business and Profession`s Code):. OWNER ❑ 1, as owner of the"property; am exclusively contracting MAIL with licensed contractors to construct th"e,project (Se"c- ADDRESS,,� , ffa tion 7044,Business.and Professions Code). CITY e :� TEL.NO:. • CONSTRUCTION LENDING AGENCY... i C .. • I hereby affirm that there is,a construction lending agency for CONTRACTOR I performance of the work for which this permit Is Issued Meta. (Sec.3097,Civ.'C.). . ADDRESS 0' Lender's Name q CITY rn liL' ?EL.NO Lender's Address STATE >- LIC: I certify that'I have read this application,and state that the above LICENSE NO. . ,yi .CLASS l.r information is correct. I agree to comply with all County ordinances and State laws re ating to building construction,and hereby,authorize representativeof this uryty to enter upbn:the above-mentioned property fo specti purpos SEE REVERSE FOR EXPLANATORY LANGUAGE ' . SIGNAT E LICANT O AG DAT -