HomeMy Public PortalAbout4913 HELEO AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89
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I hereby76A364C APPLICATION FOR PERMIT
affirm that I have a certificate of consent to self insure, L #
or a crortificate of Worker's Compensation Insurance, or a certified E E ,H
HEATING-VENTli_ATING -ASR CONDITIONING .
copy thereof(Sec. 3800 Lab. C.) �` y
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 q
department. (PRINT OR TYPE ONLY) ADDRESS
LOCALITY
Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE _
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. Ta 1m* �NEAREu/t iw
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
(This section need not be completed if the work involved by the ASSESSOR
permit is for one hundred dollars $100 or less. MAP BOOK PAGE PARCEL
P ( ) ) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit ✓✓
is issued, I shall not employ any person in any manner so as to BOILER,BTU
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become subject to the Workers'Compensation La s. T o
d COMPRESSOR,BTU � r7
Date r ^ Applicant VENTILATION SYSTEM APPROVALS DATE INSPECTOR'S SIGNATURE
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL 4_5_.q`6`
444
provisions or this permit shall be deemed revoked. FURNACE: FAUGRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU 1s, 6 o� VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect.
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License Number Lic.Class
' ACCT. a
Contractor Date 3303 126.700
❑ I am exempt under Sec. Plan Check fee1 ITEMS 1 S Q
B.&P.C.for this reason PERMIT ISSUING FEE$ O
Date: TOTAL FEE CHECK
126.70
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Signature PLAN CHECK APPLICANT CHANGE .00 to
OWNER-BUILDER DECLARATION Z
I hereby affirm that I am exempt from the Contractor's License Law NAME ► i7 t1 fynil o
for the following reason (Section 7031.5, Business and Professions 0000`000,1 11121/95
Co )' ADDRESS
I, as owner of the property, or my employees with wages 3390 1 AM 9;37'
as their sole compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale (Section 7044, r _
Business and Professions Code). OWNER
❑ I', as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS � .� eO TCU
tion 7044, Business and Professions Code). p.
CONSTRUCTION LENDING AGENCY CITY Tem(L Ci..,-i TEL.NO. D%7 0
I hereby affirm that there is a construction lending agency for CONTRACTOR ,
the performance of the work for which this permit Is issued Ot�N
(Sec. 3097,Civ.C.).
ADDRESS
Lender's Name
CITY TEL.NO.
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
and State laws relating to building construction,and hereby authorize
representatives of this County to enter upon the above-mentioned
property for insp tion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
two-qS
SIGNATURE ' APPL CAN ORAGENT DATE