HomeMy Public PortalAbout6032 IVAR AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89 �����^���®� ®U11 I�L�If1111!lII�� n�
- 76A364C � (�' 0
I hereby affirm that I have a certificate of consent fo self insure, ��AAE GREEN.
or a certificate of Worker'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.
Certified'copy is.filed witn.tlie county building inspection FOR APPLICANT TO FILL IN BUILDING
PRINT OR TYPE ONLY
department. ; _( ) ADDRESS.
Date' 'Applicant LOCALITY.
• NO. TYPE�OF APPLIANCE•OR EQUIPMENT .FEE t -
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST_ r a
CROSS'ST
COMPENSATION INSURANCE
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($1-00)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 any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws. D�
COMPRESSOR,BTU
APPROV DATE,. INSP T R'S SIGNATUR
Date �` Applicant ` - 'VENTILATION SYSTEM Al
NOTICE TO APPLICANT: If, after making this Certificate ofROUGH
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 SUSPENDED UNIT `
(commencing with Section-7000)of Division 3 of the Business and 1 HEATER: WALL (p
Professions Code, and'my license is in full force and effect.
License Number 1 Lic.Class IJ�
C �
Contractor �`v '' Date " D 0
❑ I am.exempt under Sec.
Plan,check fee U
B.&P:C.for this reasonPERMIT ISSUING FEEt8r
Date: TOTAL FEE,' 9D
ACa:T°g w
Signature �. / d
PLAN CHECK APPLICANT 3303 53-90 •Z
OWNER-BUILDER DECLARATION TTT[CMc >_�
hereby affirm that'I am exempt from the Contractor's,License-Law NAME, .1 1 G11�7•
for the following reason (Sectionr_ 7031.5, Business and Professions, e' ` D _� °
.Code): - TOTAL'
_. 3 e 90
ADDRESS L1 9
El .•,I, as owner of.the property, or my,employees with wages. � - CASH 53n9b
as their sole compensation, will do the .work and the CITY ' TEL.NO. : AIRGE °ItlJV
structure.is not intended or offered for sale (Section 7044, '
Business and Professions Code). OWNER `
I,:as owner of the property, am exclusively contractingMAIL
n��1f�yy t�f7tli ! /O
with licensed contractors to construct the project (Sec-,. ADDRESS �' � _ [,ter 00000 01. 5 v!76
tion 7044, Business and Professions Code). ' ` tt oot� i
CONSTRUCTION LENDING AGENCY CITY TEL.NO. R�7Y AMua5.
I hereby affirm:that-there is a construction lending agency for 7.
CONTRACTOR Qy� KJ�
the performance,of the work for which this permit Is issued O
(Sea 3097,Civ.C.). D
ADDRESS 2A CS
Lender's:Name
CITY. TEL.NO.
7�Z
Lender's AddressSTATE ^ LIC. 22
certify that I have read this application and'state that the above LICENSE NO.. 3 /q CLASS ` r-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 for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE`
SIGNATURE OF APPLICANT OR AGENT DATE -