HomeMy Public PortalAbout6122 IVAR AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION '20-0046 DPW 9/89 nI�p �r
I hereby affirm that I have a certificate of consent to self insure, 76A364C APLICAIl ®N ®R PERMT
or 'certificate of•Workei'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.
❑ Cegified copy is hereby furnished.
Certified co is filed with the'count 'Idi 'i 's echo FOR APPLICANT TO FILL IN BUILDING t
.Iy�J�✓� .. Y P ADDRESS
/ - department. � - (PRINT OR TYPE ONLY) - � ._
Date/0-191L
Applicant' NO. • TYPE OF APPLIANCE OR EQUIPMENT,'. FEE' LOCALITY T!f r
CERTIFICATE OF EXEMPTI ^FRO�Q '.
ERS', NEAREST
COMPENSATIO INSURACROSS ST. /J
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($100)or less.) AIR HANDLING UNIT,CFM -
DISTRICT NO, _ PROCESSED BY
I certify that in the performance of the work for which.this permit
is issued,l shall not employ'an•y person in any manner so as to BOILER;BTU
become subject to the Workers'Compensation Laws / 94
COMPRESSOR,BTU _QQQ - (o - -
- - APPROVALS.. DATE INSPECTOR'S SIGNATOR
Date Applicant VENTILATION SYSTEM
4NOTICE TO APPLICANT: If_after*making this Certificate of ROUGH j
;Exemption,you `should become subject to the-Workers'Compensation. EVAPORATIVE COOLER
provisions of the Labor'Code, you must'forthwith comply with such FINAL
provisions;or this permit shall be-deemed revoked. FURNACE'. FAU GRAVITY
LICENSED CONTRACTORS,DECLARATION FLOOR" TU S VALIDATION
L•hereoy affirm.that I am licensed under provisions of Chapter 9 SUSPENDED -UNIT.'
(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL' -
Professions Code,and my license is in'full force'and'effect.
License'Number� (J � Lic.Class C-2�
A0 -_L/- o
Contrac�aexempt
Date /
u.d Sec. Plan Check fee U
C.for t s reason PERMIT. •FEE.$ ji0. '0.
Date: TOTAL FEE U
W
'Signature 8 d.
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT -+t'•i,s (/)
I hereby affirm that I am exempt from the Contractor's.LicenBe Law NAME ' D 1 `='� a ) =`l' Z
forthe following reason (Section 7031.5, Business and Professions T r.
Code): ADDRESS' 3 t s�E f ,
I, as owner of the property, or my employees`wilh wages I(;
!-IL06 -
'as.their sole-compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale (Section 7044, ; HE K,
Business and Professions Code). OWNER i.-
❑ I,,as owner of.the property, am exclusively contracting' ~` •H') 'j °If?`•
MAIL - ��' /
with licensed contractors to construct the.project (Sec- ADDRESS 2 V
tion 7044, Business and Professions Code): '
CONSTRUCTION LENDING AGENCY CITY TEL.NO.a �(; -j;)"0 #_ '11 -`_94
I hereby affirm that there is a construction lending agency for ?� ?a hji"I a i"?'
the performance of the work for which this'permlt Is issued CONTRACTOR \_ O Z�✓C s
(Sec.3097,Civ.C.). 1It �I_�t r
ADDRESS `Hyl ✓1
Lender's Name I�- �•�
CITY v TEL.NO. J '
Lender's Address STATE LIC:'
certify that I have read this application and state that the above uCENSE NO. "S 2Z lis CLASS G 2
information is correct. I agree to comply with all County ordinances
and State laws relatingio.building c struction,and hereby authorize
representati of ' Cc u ty to a ter upon the above-mentioned
property ins ionr S. ._ SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE Q APPLICANT OVNT DATE - -