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HomeMy Public PortalAbout6148 IVAR AVE_Mechanical__ a WORKER'S COMPENSATION DECLARATI 20-0046 DPW 9/89 l�l�p �,r. 2 ��'l (� n n /�{IDI I hereby affirm that I have a certificate of co nt to self insure,. `76A364C i AI�IrL�OCQ 11 0®NFOR PLSRuHu�TI1�� or a certiSicate of Worker's Compensation surance, or a certified' HEATING,-VENTILATING -SIR CONDITIONING copy thereof(Sec.3800'Lab:C.) .. ter.. Policy No._ C party COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS ' BUILDING AND SAFETY DIV. Certified copy is eby furnished. ❑ Certified y is filed with'the'county building inspection_ FOR APPLICANT TO FILL IN -'. BUILDING depart nt." - (PRINT OR TYPE ONLY).: - ADDRESS Date - Applicaht _ NO. TYPE OF APPLIANCE OR EQUIPMENT- _ FEE LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST lI • T. COMPENSATION INSURANCE © CROSS This section need not be com leted if the work involved b the ASSESSOR 0,9"L o —y ( lY P .. � MAP BOOK.� G PAGE O� PARCELQD /- permit is for one hundred dollars($100)orless.) AIR HANDLING UNIT,CFM DISTRICT NO.. PROCESSED BY I certify that in the performance of the work:for which this permit is issued, I shall not'employ any person in:any manner so as to I BOILER,BTU become ub' ct to the Workers' Compensation Laws. —r COMPRESSOR,BTU" "o APPROVALS, -- -� .APPROVALS - DATE SPECTOR'S SIGNATURE Date 1Z_ Applicant - VENTILATION SYSTEM IN NOTIC TO'APPLICANT:'If,,aiter• i Certificate of ROUGH Exemption,you should become'subject to t orkers'Compensation EVAPORATIVE COOLER provisions of'the Labor Code, you mu orthwith comply with such FINAL, provisions or this permit shall be d ed revoked. FURNACE: FAU GRAVITY / LICENSED CONTRAC ORS DECLARATION f� FLOOR BTU (p Q VALIDAT N I hereby-affirm that I am licensed under provisions•of,Chapter 9 HEATER: SUSPENDED-' UNIT• (commencing 1w ith Section 7000) of Division 3 of the Busines and WALL Professions Code,and my license is in full force,and effect L I License Number Li ass a� D 33303 . 105,70 }, 1 ITEMS a Contractor Date 0, am exempt unde Plan check fee ec. TOTAL 105®1101 v B.&P.C.for Is reason PERMIT.ISSUING FEE$ d CHECK 105.705' a Date: TOTAL FEE d . t.NAhI�E 00 w .00 Ignature IZ OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT f . '! co 0000-000 1 9h _ I hereby affirm that I am exempt from the Contractor's:License.Law F E t 7 for the following reason (Section 7031.5, Business and-Professions 6iTl 1. Alt'1rJa01 �ode`): RE S +// (� I, as-owner Of the property, or my employees with wages zica v'J as their sole compensation; will do the work and theCITY TEL:NO. structure is not intended or offered for sale (Section 7044, I/ Business and Professions Code). OWNER ❑ I, as owner of the property, am exclusively contracting MAIL with licensed contractors•to construct the project (Sec- ADDRESS tion 7044, Business and Professions Code). ITY TEL.NO. CONSTRUCTION LENDING AGENCY C hereby affirm that there is a construction lending agency for CONTRACTOR the performance of the work for which this permit Is issued W (Sec,3097,Civ.C.). ADDRESS Lender's Name CITY TEL.NO. Lender's Address STATE LIC... certify that I have read this application and state that the above LICENSE NO. CLASS information is correct. I agree to comply with all County ordinances and-State laws relating to building construction,and hereby authorize representatives of this C y to enter upon the above-mentioned property for ins o /. 5/ SEE REVERSE FOR EXPLANATORY LANGUAGE l NATUR All R AGENT DATE " ' '