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Home My Public Portal About5936 HART AVE_Mechanical__ 'WORKER'SCOMPENSATION DECLARATION 7DPW 9/89 6A364C ��r+ ��n ®� ��r,�,�'� MAE Ihereby affirtn�fiat,l have.a certificate of consent to self insure, l� �I uVuGREEK or a tjitf icatel,of Worker's Compensation Insurance, or a certifiedHEATING-VENTILATING-AIR CONDITIONING copy,(hefeof(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 BUILDING ADDRESS department., (PRINT OR TYPE ONLY) •� PP LOCALITY Date _' Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE °` CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST. r COMPENSATION INSURANCE - CROSS ST: ABSORPTION UNIT,BTU ASSESSOR' (This section need not be completed if the work involved by the MAP.:BOOK PAGE PARCEL permit is for one.huridred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO:- PROCESSED BY - - 1 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 ry T become subject to the Workers' Compensation Laws. • Q Y 1e� COMPRESSOR,BTU Date ' �( Applicant r APPROVALS DATE NSPECTOR'S SIGNATURE VENTILATION SYSTEM NOTICE' O APPLICANT: If, after making"this Certificate of I I.RbUGH -o 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 GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU O o©o VALIDATION I,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 Lic.Class to JU11t L3 0. . S D , o CGntractor Y\-4 '�1�.� '`'-Iale -3 I am exempt under Seca Plan check fee U B.&P.C.for this.reason PERMIT ISSUING FEE � 1�Q O Date: .TOTAL FEE a ('� d Signature CO PLAN CHECK APPLICANT OWNER-BUILDER DECLARATION Z 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 I, as owner.of the property, or my employees with wages as their sole compensation, will do the work and the CITY TEL.NO. j•_ __ ,, Structure is not intended or offered for sale(Section 7044, .Business and Professions Code).' OWNER es co' Ati Cl, _ I, as owner.of the property, am exclusively contractingMAIL F, s s} yL -y e� € with licensed contractors to construct the project (Sec- ADDRESS b 8 �1\5 �( f . tion 7044, Business and Professions Code). CHfv.f CITY �p TEL:NO. CONSTRUCTION LENDING AGENCY e lllCJ C ; .I I hereby affirm thaf there Is a construction lending agency for #i`E T1w s ' the performance of the work for which this permit Is issued CONTRACTOR" I-AF u e � A(Q (Sec.3097, Civ. C.). 1 t D. ADDRESS P•d. Qx10 Lender's Name CIT ( Y TEL.NO. 7- 1 i 's -- S,F Lender's Address STATE LIC: I certify that) have read this application and state that the above LICENSE NO. l 6 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 propert f"pection, purpose SEE REVERSEFOR EXPLANATORYLANGUAGE �U EGENT DAT