Loading...
HomeMy Public PortalAbout9948 HOWLAND DR_Mechanical__ WORKER'S COMPENSATION DECLARATION 76A364C 46 DPW 9,69 APPLICATION FOR PERMIT 76A3 heeeby affirrti that I have'a certificate of consent to self insure, or a certificateLIME GREEN,worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING copy thereof(Sec.3800 Lab.C.) u Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. ❑' Certified copy is hereby furnished. ❑ copy y g'inspection FOR APPLICANT TO FILL IN BUILDING Certified co Is filed with the count buildin ADDRESS department. (PRINT OR TYPE ONLY) Dale Applicant LOCALITY 1 T� C1'r NO. TYPE OF APPLIANCE OR EQUIPMENT FEE `lam CERTIFICATE OF EXEMPTION FROM WORKERS' NEARESTCROSS ST. COMPENSATION INSURANCE ABSORPTION UNIT,BTU (This section need not be completed if the work involved by the ASSESSOR MAP BOOK PAGE PARCEL permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY I certify that in the performance of the work for which this permit is issued, I shall not employ anyp n in any mann so as to BOILER,BTU become subject to the Workers'Co en ation LY Z COMPRESSOR,BTU � t D Date ^9a Applicant APPROVALS DATE INSPECTOR'S SIGNATURE VENTILATION SYSTEM NOTICE TO APPLICANT: If, after m ing this Certificate of ROUGH - Exemption,you should become subject to he Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code, you must forthwith comply with such FINAL 3l provisions or this permit shall be deemed revoked. FURNACE: FAU VI / LICENSED CONTRACTORS DECLARATION FLOOR BTU — &6c? VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 HEATERSUSPENDED UNIT (commencing with Section 7000) of Division 3 of the Business and : WALL Professions Code,and my license is in full force and effect. ���1 / 17 w���S CW Lt � i License Nu er Lic.Class Q � Contractor Date v Jq -97— , U ❑ I am exempt under Sec. Plan Check fee B.&P.C.for this reason PERMIT ISSUING FEE$ 1 0 Date: TOTAL FEE p ACCT°s W Signature •O 3307 18J+r C'6 0- PLAN CHECK APPLICANT °� N OWNER-BUILDER DECLARATION ii Z I hereby affirm that I am exempt from the Contractor's License Law NAME 1 � I ITEMS for the following reason (Section 7031.5, Business and Professions , TOTAL 18,2® -E,"6 Code): /f '� CHECK Hu V i ❑ I, as owner of the property, or my employees'with wages ADDRESS t O , ��� 15 CECK 182.8 as their sole compensation, will do the work and the CITY r v l�� �� TEL.NO. / y' �ulhlaL °�I�j structure is not intended or offered for sale (Section 7044, ✓ ! H Business and Professions Code). OWNER F-1 ©a/ `O I, as owner of the property, am exclusively contracting MAIL !,L` I I' t^�f1 �rt�lJi 4�i(hn with licensed contractors to construct the project (Sec- ADDRESSqq g' QW �"0 lz V V 0 1 1 tion 7044, Business and Professions Code). -- - �yry 1 CITY / C C�'ir EL.NO. Ltl7 I tN t ii CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction n lending agecy for CONTRACTOR the performance of the work for which this permit Is issued (Sec.3097,Civ.C.). �,/ ADDRESS S `�V Lender's Name CITY 10 V TEL.NO. Lender's Address STATE LIC. I ce that I have read this application and state that the above LICENSE NO. 9 CLASS C_--2 inf rm ion is correct. I agree to comply with all County ordinances d S to laws relati g to ilding construction,and hereby authorize " pr entaat s of is ou ty to enter upon the above-mentioned ro erty for inspe tion rpose SEE REVERSE FOR EXPLANATORY LANGUAGE 1 SIGNATUPE 0F APPLICANT OR AGENT DATE