HomeMy Public PortalAbout9839 HOWLAND DR_Mechanical__ have WORKER' COMPENSATION DECLARATION 2PODO6DPW 9.69 APPLICATION FOR PERMIT LIME GREEN
hcreby'afiirm that•1 have a certificate of consent to self insure, 6A364C
are certificate of Wpiker'S Compensation Insurance, or a certified HEATING -VENTILATING - AIR CONDITIONING
copy thereoi(Sec.3800 Lab.C.)
Policy No. 1Z 9S ZCompany_�L^rJ_c� COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV..
Certified copy is hereby furnished. f'
❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING
-
department. 9 /��j,� (PRINT OR TYPE ONLY)
Date Applicant r�_ • LOCALITY F
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS A.
'CJ
ABSORPTION UNIT,BTU ASSESSOR
(This section need not be completed i/the work Involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or leas.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit / n
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws. 7 n �/ - //a C�i/JP///�•/
COMPRESSOR,BTU '?F b, O
APPROVALS DATE INSPECTOR'S SIG TURF
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
you must forthwith cam
provisions of the Labor Code, y comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY / bVALIDATION
LICENSED CONTRACTORS DECLARATION FLOOR BTU /i
1 hereby affirm that 1 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.
License Number Lia CIas4 o b ,
/ 04
p l'Z� o
Contractor Date V
❑ I am exempt under Sec. Plan Check fee Q
B.BP.C.for this reason PERMIT ISSUING FEE $ 'f p U
Date: TOTAL FEE Cj 9� d
Signature
OW EA �_ PLAN CHECK APPLICANT
BUILION p Z
I hereby affirm that I am exempt from the Contractor's License Law NAME ► CL
for the following reason (Section 7031.5, Business and Professions
Code): ADDRESS ACCT.
❑ I, as owner of the property, or my employees with wages 3303 109.90
as their sale compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale (Section 7044, '/ 1 ITEMS
IS
Business and Professions Code). OWNER
El /1, as owner of the property, am exclusively contracting MAIL /[�_f ry
6 / TOTAL 109 . 90
with licensed contractors to construct the project (Sec- ADDRESS z O� / CHECK 109.90
tion 7044, Business and Professions Code). e� �-�7
CIU �'E ( TEL.NO. 2$7 /�1�6 CHANGE .00
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for CONTRACTOR
the performance of the work for which this permit Is issued i�ci rrFl ...
(Sec.is N Civ.C.). ADDRESS 0000-0001 1/26/96
0 1 H
Lender's Name 44680 1 -- A1110:17CITY TEL.N 33P a C
Lender's Address STATE ` LIC. /A >
I certify that I have read this application and state that the above LICENSE NO. 6 CLASS l_
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
prop
ro ty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
C,2
SIGNATURE OF APPLICANT OR AGE — DATE