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Home My Public Portal About4856 HELEO AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89 APPLICATION FOR PERMIT LIME GREEN • 76A364C I hereby affirm tbat 11have a ceytificate of consent to self insure, .r � or a certifidate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING copy thereof(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 p3� dep m nt., (PRINT OR TYPE ONLY) ^ I LOCALITY Date Applicant ✓ NO. TYPE OF APPLIANCE OR EQUIPMENT FEES CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST CROSS ST. COMPENSATION INSURANCE ABSORPTION UNIT,BTU This section need not be completed if the work involved ASSESSOR � J PARCEI�/J ( b P Y the MAP BOOK PAGF��/ permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to BOILER,BTU d �0� . become subject to the Workers'Compensation Laws. / COMPRESSOR,BTU APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT: If, after making this Certificate of ROUGH Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code, you must forthwith comply with such FINAL provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU _ VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED—UNIT— (commencing USPENDED UNIT(commencing with Section 7000) of Division 3 of the Business and WALL Professions Code,and my license is in full force and effect. 410 . {� License Number 16,3-'D( ( Lic.Class /8 11 , 0- Contractor,J/ `�fL Date 1 � Q ❑ I am exempt under Sec. Plan check fee AfiCT°g CC B.&P.C.for this reason PERMIT ISSUING FEE$ 3v :, O Date: 330.3 66 i 5Ov TOTAL FEE p I ITEMS LLI Signature (- OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT �T��ij..j�iTT�AL 66 - 50 Z 1 hereby affirm that I am exempt from the Contractor's License Law NAME , CHECK LL 9��^} for the following reason (Section 7031.5, Business and Professions CHANGE 90° t1 Code): ADDRESS CHANGE •00 ❑ I, as owner of the property, or my employees with wages as their sole compensation, will do the work and the CITY TEL.NO. GW structure is not intended or offered for sale (Section 7044, 0000-0001 11/29/95. Business and Professions Code). OWNER ❑ I, as owner of the property, am exclusively contracting MAIL _ �— 3 P� 1 M1?°°,sI with licensed contractors to construct the project (Sec- ADDRESS � tion 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY CITY TEL.NO. `��' ` I herebypperformance' affirm that there is a constructions perm agency for CONTRACTOR G` the erformance'of the work for which this permit Is issued l (Sec.3097,Civ.C.). ADDRESS Lender's Name TEL.NO/P�' ,_'? CITY V Lender's Address STATE LIC. I certify that I have read this application and state that the above LICENSE NO. � � CLASS information is correct. I agree to comply with all County ordinances a4arelating to building construction,and hereby authorize reof this County to enter upon the above-mentioned pspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATOR F APPLICAN O DATE