HomeMy Public PortalAbout6203 HART AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/69 //��nnn (�//� TOR:
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or arcertifi¢ate of at.l have a certificate of consentt6 self insure,
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Worker's Compensation Insurance; or a certified k,
copy thereof(s :3800 Lab.C:) HEATING=VENTILATING-qIR CONDITIONING. '
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PPoliir i Nor a l/ Company r COUNTY-OF LOS ANGELES DEPT OF PUBLIC WORKS : BUILDING AND.SAFETY DIV'
Ce 'led copy is•hereby furnished..
y g inspec ion FOR APPLICANT,TO FILL'IN ADDRESS
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C rtified co Is filed with the c( building tl�/[//.
%d qa nt- PP (PRINT OR TYPE ONLY) i
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,LOCALITY
Date: A licant Nq: TYPE OF APPLIANCE OR EQUIPMENT' FEE
�f CERTIFICATE OF,EXEMPTION FROM WORKERS.'`' NEAREST
COMPENSATION INSURANCE CROSS_ST
• 'z ABSORPTION UNIT,,BTU
(TASSESSOR -
his section,need`not be completed if,the.work involved by the • MAP BOOK, ` PAGE ,PARCEL.
° ;.permit is for one,hundred dollars($100)or.less.) ,.. AIR HANDLING,UNIT,CFM`
DISTRICT.NO.
I certify that-in the performance of the work for which this permit
s issued, I'shall not ema '.m
ploy any person In nyanner so as to` BOILER,BTU
be..come subject to the Workers'Compensation Laws.
1 COMPRESSOR,BTU- AP •INSPECTORS SIGNATURE
,. •'.., . - ,. - „,. -:: ,:.- .: � {
PROVALS � , DATE
Date 'Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after 'making'this Certificate of ROUGH:,'.
Exemption,you should become subject to the Workers'Compensation'
EVAPORATIVE COOLER: 4
,provisions of,the,Labor Code,"you must forthwith,comply with such l;bZ
.provisions or this permit shall be revoked.': FURNACE: FAU AVITY
FINAL
LICENSED CONTRACTORS.DECLARATION ;FLOOR BTU :VALIDATION J
I hereby affirm that,l am'licensed under provisions of Chapter 9, SUSPENDED UNIT
•HEATER:.
(commencing-,with Section 7000)of Division 3'of the,-Business-and WALL
Professions Code and'my license is in full force and effect:
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License,Number" r / Llc Class`s
AL
/ e '0
orAPMe V
Plan chock-fee 1 ITEM
I am exempt under Sec _
B.&P.0 forthis.•reason PERMIT JSSUING FEE$ �; j�I 0
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_..
Date'-
'TOTAL FEE t('y
C� ,a
Signature , ... „ HA
PLAN CHECK APPLICANT:' - P.Ctll,
CHANGE' ' _cn
OWNER-BUILDER DECLARATION;.' �_
I hereby affirm that'_I am'exempt from the.;Contractor's License Law: NAME f yr! Mit k o
for the following reason(Section•7031.5,`Business.and Professions. D I;If�pzt�+JV i 11� j��7 ,•1 [p,1 i
',Code): ADDRESS - ,.T)''jt� 1 ._•,,�� (f}s i �. ..
,1,,as owner,of,the property;or my employees with wages J
.as their sole compensation, will do the Work'and'the CITY TEL.NO:
a
structure is not intended'or offered for sale (Section 7044; :.
Business-and'Professions Code). OWNER
1, as owner of the property, am.exclusively contracting
MAIL' •'
wit IT.licensed contractors to construct the project(Sec- ADDRESS.
tion 7044„6usiness and Professions Code).. Qy
CONSTRUCTION LENDING AGENCY CITY w TEL NO
1,hereby affirm that there is a construction lending agency`,for CONTRACTOR r ;
the,performance'of the wocK='for which this-permit isissuedD, .,
(Sec 3097„Civ.C.):`
ADDRESS - _ -
6
Lender`s Name
CITY TEL NO:
Lenders Address STATE., LIC_'
l.certlfythat I have read this application and.state that the aboveLICENSE NO. CLASS
information is correct. I agree to;corriply.with all County.ordinances
and'State laws relating to building construction,and hereby authorize.
represe tatIves of this County_to enter upon the above-mentioned
grope for inspection purposes:.-
SEE REVERSE FOR EXPLANATORY LANGUAGE
SlqVURE-OF APPL T OR AGENT - DATE