HomeMy Public PortalAbout6013 HART AVE_Mechanical__ 4. WORKER'S COMPENSATION DECLARATION .20-0046 DPW 9189 LIPAE
I hereby.affirmAhat I Have a certificate of consent to;self insure, 76A364C �,�^ ���T NN ��� p����� �IC
or a certificatedf WorkersCompensation Insurance or 6 certified ,
HEATING -VENTILATING.- AIR CONDITIONING
copy thereof(Sec.'S8001ab.,C.)
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PolicyNo. p�7 c?7F �"
1-� Y � Company / COUNTY OF LOS ANGELES ' -DEPT OF PUBLIC WORKS ., BUILDING AND SAFETY'DIV ,
❑. .Certified co is hereby furrnshed. ".
❑- ' Certified copy is filed'with the county.ouilding inspection : FOR'APPL'ICANT TO�FILL IN ADOR SS
kv 13.
department.' (PRINT OR TYPE ONLY)
.�•7�_ LOCALITY
Date v Applicant.� '1 %«L NO., TYPE,OF APPLIANCE OR EQUIPMENT "r' FEE
NEAREST'
CERTIFICATE OF'EXEMPTION FROM WORKERS'
CROSS ST:
COMPENSATION INSURANCE ABSORPTION UNIT;BTU
r ..I. .. ASSESSOR.'—
(This section need not be completed if the work involved by the MAP BOOK: PAGE PARCEL ,
permit is for one hundred dollars,($100)*or less.) AIR HANDLING UNIT,CFM-
i ' --- DISTRICT NO.• PROCESSED BY
I certify that in the,performance of the work for which this permit
is issued, I shall notemploy'-any person in'any manner-,so asp to BOILER,BTU
becomesubject to the Workers'Compensation Laws ��2 Svc C
O' • COMPRESSOR,BTU ' ' ... PROVALS� DATE INSPECTOR:
'S SIGNATURE
Date Applicant VENTILATION SYSTEM
`-'NOTICE-TO APPLICANT: -If, after making*•this Certificate of''. ROUGH
Exemption,you should become subject to the.Workers'Compensation _
provisions of the Labor Code,.you'must forthwith comply with such EVAPORATIVE'COOLER FINAL ] Z�
provisions or this permit,shall'be deemed revoked. FURNACEFAU—GRAVITY '
LICENSED CONTRACTORS DECLARATION FLOOR BTU'-2VALIDATION
I,he[eby affirm that I am licensed under provisions of Chapter 9: SUSPENDED• UNIT
(Commencing with Section 7000) of Division 3.o!the:Business'an'd., '`HEATERi y WALL"
Professions Code,and'my'license'is'in full force and effect.
License Number IOLlc"Class
Contracto°r �2� � Date 4�1 `tr� O
Plan check fee , T EI
I amsxempt under Sec., _l
❑ _�
B:&P:C.for this reason PERMIT.ISSUING FEE$ t`-
Date: TOTAL_FEE-
f_: - L' W
r.. ` W
Signature a ! Y
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANTZ
I hereby affirm that I am exempt from.the Contractor's License Law-- NAME J
for the following reason 'action 7031.5; Business and Professions /� s
`•s s
Code),:, ADDRESS G7— c f -` °-
❑ 1, as owner of the property, or my employees with.wages -as their sole compensation, will do the work and the CITY
structure is not intended.or offered,for sale (Section 7044, A �,J
Business and Professions;Code). OWNER i•r - � /9
❑' I, as owner of the,property, am exclusively contracting MAIL.
with licensed contractors.to construct the project (Sec- ADDRESS -L
tion 7044, Business and Professions Code).
CONSTRUCTION,LENDING AGENCY. CITY �. TEL.NO:
I hereby affirm that there is a construction lending agency for"
the performance of the work for whicWthis permit Is Issued CONTRACTOR'
(Sec.3097,Civ.C.).
ADDRESS. GJ`
Lender's Name - a
CITY y5� TEL O.;1 D 7.
tl
Lend`er's Address STATE LIC.
certify that 1-have read this application and.state that the above uCENSE'NO. ?� 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
TU RM F APPLICANT O AGENT ? DATE