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HomeMy Public PortalAbout8733 HERMOSA DR_Mechanical__ 20� WORKER'S hveacertificate COMPENSATION DECLARATION 76A3"DPW 9189 APPLICATION FOR PERMIT LIME GREEN. 76A 16 I hereby affirm that 1 have a certificate of consent to self insure, or a certificate of Worker's Compensation Insurance, or a certifies - - HEATING•VENTILATING -AIR CONDITIONING copy therY$�f(S 3800�38j0�0 1Lab.C�J Gam! Policy NI �`�L'✓ t'o�pany_V`y'"+/� Al!C �C� COUNTY OF LOS ANGELES "' "— DEPT"OF'PUBLIC WORKS BUILDING AND SAFETY DIV. Candied copy is hereby furnished. _ Certified co Is tiled with4thecounlybu' in ins cti n FOR APPLICANT TN FILL IN BUILDINGepprtm n py (PRINT C TYPE ONLY) ADDRESS Date •� AppliLOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EMP ON FROM WORKERS' - NEAREST COMPENS NINSURANCE CROSS ST. /OC] ABSORPTION UNIT,BTU 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 leas.) AIR HANDLING UNIT,CFM olsm�No, PRocEsssG BY I certify that in the performance of the work for which this permit is issued,eI shall not employ any person in any manner so as to BOILER,BTU become subject to the Workers'Compensation Laws. eat COMPRESSOR,BTU APPROVALS HATE INSPECTCe'$$IGNANRE 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 Q FINAL provisions or this permit shall be deemed revoked. FURNACE: FAU III GRAY'_ LICENSED CONTRACTORS DECLARATION FLOORBTU - - V- VAUDATION 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: MALL Professions Cade, and my license is in full force and effect. License Number Lia Class O - ,:.�137 `0.gc ._ ._ �, 1' ITEMS o Comra tet - -' -"- TOTAL 50:55 U Plan check fee m exempt under Sec. 'S +. CHECK JDacJ Q B.BP.C.for this reason - PERMIT ISSUING FEE$ r''-- - t."GE - -. -.- OU O Date: TOTAL FEE W Signature 0000-0001 J1r9 CHECK APPLICANT OWNER-BUILDER DECLARATION (n 8414 1 AMUJ�45 Z I hereby affirm that I am exempt from the Contractor's License Law NAME 111110. for the fallowing 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 TEL.NO. structure is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER ❑ I, as owner of the properly, am exclusively contracting MAIL 56V It, i9L4 with licensed contractors to construct the project (Sec. ADDRESS tion 7044, Business and Professions Code), CONSTRUCTION LENDING AGENCY CI TEL.NO. Q 10 �D I hereby affirm that there is a construction lending agency for r the performance of the work for which this permit Is issued CONTRACT ,. _ _ _ - (Sec.3097, Civ.C.J. /�_ .. ' _ - .M ._ :•Y1:7_E'f7G T„ - AODRES Lender's Name CI e� TEL.NO. Lender's Address LC I certify That I have read This application and Stale that the above LICENSE NO. © CLASS(,r information is correct. I agree to comply with all County or and Stale 'at to Iltling construction,and her by auth rize rep s of�s to en the ab a-men ned _ - r ins cti s SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATUREGF APPLICANT OR AGENT D -