HomeMy Public PortalAbout6047 IVAR AVE_Mechanical__ pNOR KERS' COMPENSATION DECLARATION s n P P C n Y M N FOR n 2 RN T
'I hereby�ffirm''tFiet I have a certificate of consent tofself hll!"Il—L� l�1 ITV -FOR L!"LSl1�I1Vll
nstr;,e, or a certificate of Workers Compensation Insur7nce, HEATING _ VENTILATING _ ��� CONDITIONING
•ot G certified copy thereof (Sec. x'.900,gab. C.) 76A364C
.20-0046 DPW 9/88`
Policy No, Company
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. (PRINT OR TYPE ONLY). ADDRESS ®� A/ ,4 le
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST o ® �
COMPENSATION INSURANCE CROSS ST. ry 6
(This section need not be compl'e'ted if the work involved by ABSORPTION UNIT; BTU DISTRICT NO. PR SSED BY,
- + the permit is for one hundred dollars ($100) or.less.)
I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM Aye(
-permit is issued, I shall not employ any person.in"any manner p►VV
BOILER, BTU
so as to become subject to the Workers'Compensation Laws. APPROVALS DATE e�I-N�SPECTOR'S SIGNATURE
Date Applicant COMPRESSOR, BTU ' ROUGH 2t O! I
NOTICE TO APPLICANT: If, after making this Certificate'of VENTILATION SYSTEM FINAL
Exemption, you "should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VA ATION
with comply with such provisions or this permit shall be deem-
ed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION. FLOOR BTU•-
;I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED—UNIT
(commencing
USPENDED UNIT(commencing with Section 7000)of Division 3 of the Business WALL.
and Professions Code,and my,license is in full force and effect.
License Number Lic. Class �+ D O
Contractor Date
EI am exempt under Seca 0
Plan check fee u
W
B.&P.C. for this reason. H
Date: PERMIT ISSUING FEE $
" TOTAC FEE ,
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License D
Law for the following reason (Section 7031.5, Business and NAME
ACV.Professions,Code): - HL�.•�-
I- as owner of. the property, or my employees with ADDRESS .530 _._,-4 °,
wages as their sole compensation, will do the work and t
the structure is not intended or offered for sale(Section CITY TEL. NO.
t ITEMS
7044, Business and Professions Code).
❑ OWNER TOT AL __,eg 9...7_s
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project Sec- MAIL 75
P I ( CHE':K �1. .r
tion 7044, Business and Professions Code). ADDRESS, ..
CONSTRUCTION LENDING AGENCY CITY TEL. NO: CHANGE °�III
I hereby affirm that there is a construction lending agency for
the performance of the work for which this-permit is issued CONTRACTOR
Sec. 3097, Civ. C. . D " ".
( ) _. .. I�t�1�I,J-I��11�1• �.it Z=ice Q
ADDRESS
Lender's Name 6818-,
u18 1 PM12'11
CITY TEL. NO. _'
Lender's Address
I certifythat I have'read this application and state that the STATE- LIC.
PP LICENSE NO. CLASS
above'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 y
upo bove-mentioned property for inspection purposes: -
SEE REVERSE FOR EXPLANATORY LANGUAGE
nature of Applicant or Agent Date Its