HomeMy Public PortalAbout8803 HERMOSA DR_Mechanical__ WORKER'S COMPENSATION DECLARATION 0-0 4
MA34C 9/8e APPLICATION FOR PERMIT LIME GREEN
I f:, affirm that.I have a certificate of consent to self insure,
or a'I eitl4ijate of.Worker's CompenZ::i�a�DCIUNTY
HEATING -VENTILATING-AIR CONDITIONING
Copy.dierreee L Sec.3800 Lab. CC
Policy Ifo. � 3`Coin OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished. ,
.� Certified copy is filed with the u tli g' coon FOR APPLICANT TO FILL IN BUIJR 56 ob 0
dep ment. (PRINT OR TYPE ONLY)
�'
Dat ApplicaLOCALITY
NO, TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EX TION FROM WO S' NEAREST
CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
(This section need not be completed if the work involved by the ASSESSOR
MAPBOOK PAGE PARCEL
permit i3 for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DistflwT No. PRocSsssD ev
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
become subject to the Workers' Compensation Laws.
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'$$IGNANflE
Dale 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 HEATERSUSPENDED UNIT_ J.12
(commencing with Section.7000) of Division 3 of the Business and : WALL —
Professions Code, and my license is in full force and effect. 7—,D
License Numb P /7�Lic.Class 0—
_ ►
Contractor Id
❑ am exempt under Sec. Plan Check fee V
cc
B'BP.C.for this reason PERMIT ISSUING FEE $ 4
Date: TOTAL FEE i W
Signature - (-
PLAN CHECK APPLICANT CD
OWNER-BUILDER DECLARATION Z
I hereby affirm that I am exempt from the Contractor's License Law NAME ► _
for the following reason (Section 7031.5, Business and Professions
Code): ADDRESS
F-1a.I, as owner of the property, or my employees with wages "�'�'T
as their sole compensation, will do the work and the CITY TEL.NO. ;07 �c•�(p(
structure is not intended or offered for sale (Section 7044, `
Business and Professions Code). OWNER i -r i F 1_
❑ I, as owner of the property, am exclusively contracting MAIL 1 ',T/ /` •j} AL 25 a 00
with licensed contractors to construct the project (Sec- ADORES 3 (fUJ
tion 7044, Business and Professions Code). rf�(_
CONSTRUCTION LENDING AGENCY CITY qTEL.
hereby affirm that there is a construction lending agencyfor Or ► CHANGE C;7!
the performance of the work for which this permit Is issued CONTRACTOR _.
(Sec. 3097,Civ. C.). ,
ADDRESS
Lender's Name
CITY .NO. �I�r
/. �/� C•-/ ii
Lender's Addressp �i ii•=N •"'
STATE 1�77 LIG -
I certify that I have read this application and state that the above LICENSE NO OCLASS
information is correct. I agree to comply with all County ordinances ,
antl State laws rata' to building construction,and hereby authorize
pr 0Matives t s Coumy to enter upon the above-mentioned _
rop r
,on Purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
T�
A RE OF LICA RAGENT .ATE