HomeMy Public PortalAbout8919 HERMOSA DR_Mechanical__ WORKER'S COMPENSATION,DECLARATION 20-0046 DPW 9/69 APPLICATION FOR PERMIT ���� GREEN
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I hereby affirm (fiat I have a certificate of consent to self insure,
or a cbrtificate of Woiker'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. n
❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN noo Ess -1 'q H t M® ��..
department. (PRINT OR TYPE ONLY) C `lf i
Date Applicant LOCALITY TEM LE R
N0. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST �S�A,f s-A(1 ��v�
COMPENSATION INSURANCE CROSS ST. 1'`E-1-D
ABSORPTION UNIT, c a
(This section need not be completed if the work involved by the ASSESSOR
MAP BOOK 30 PAGE Q/7 PARCEIU Z-V)
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM Ms ICT No. PROCESSED By
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws. 0� jlipi �f
COMPRESSOR,BTU
APPROVALS OAiEIN ECTOR'B SIGNgT11gE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU_G V TV
LICENSED CONTRACTORS DECLARATION FLOOR BTU �0 VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT_
HEATER: -
(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code, and my license is in full force and effect. C -
License Number Lie.Class
-fTAL S5. c- }
Contractor Date U,
❑ 1 am exempt under Sec. Plan Check fee -
B.&P.C.for this reason PERMIT ISSUING FEE$ '!'tA^;aF O
Date: TOTAL FEE ,f U
Signature I[I]I t-+)i_fk tt jl,!13?7"::LUd
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT _550 Pm _. Z
I hereby affirm that I am exempt from the Contractor's License Law NAME Ln)r+I' 1 �u�R1 ,
for the following reason (Section 7031.5, Business and Professions 1"
Code): ADDRESS
❑ 1, as owner of the property, or my employees with wagesy n
as their sole compensation, will do the work and the CITY O �F 1 1 TEL.NO 11 " 2�
structure is not intended or offered for sale (Section 7044, L W
Business and Professions Code). OWNER
1, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TEL.NO.
hereby affirm that there is a construction lendingagencyissued
for CONTRACTOR ��!»2�L ,
the performance of the work for which this permit Is issued -
(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. 1 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 inspecti8n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
ut�u„vuiM �� 9.5"
5 TORE OF APPLICANT OR fT An