HomeMy Public PortalAbout6201 IVAR AVE_Mechanical__ DECLARATI
WORKER'S COMPENSATION eacertificate
of consent to 20-0046 DPW 9,89 APPLICATION FOR PERMIT LIME GREEN
76A364C
I heraby'affir�ri that I have a certificate of consent to self insure,
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 y inspection
is filed with the count building FOR APPLICANT TO FILL IN BUILDING o
PRINT OR TYPE ONLY) ADDRESS
department. (
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE G
CERTIFICATE OF EXEMPTION FROM'WORKERS' NEAREST
CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
his section need not be completed if the work involved ASSESSOR
(Tb P Y the � MAP BOOK '�. PAGE0 1 b PARCELO'& _
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 any person in any,manner so as to BOILER,BTU
become subject to the Workers'Com ensation Laws.
COMPRESSOR,BTU �"/ �d
X Date Applicant VENTILATION SYSTEM I APPROVALS DATE INSPECTOR'S SIGNATURE
NOTI E O APPLICANT: If, a r making t 's Cer I a e of ROUGH
Exemption,you should become su bct 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 GRA TY
LICENSED CONTRACTORS DECLARATION ` FLOOR BTU n�0 V LI A I N
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED—UNIT—
(commencing
USPENDED 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 Lic.Class _jf •�
a.-� -•
ar
Contractor Date 1. HEM::s 0
❑ I am exem t under Sec. Plan Check fee ., _.�
B.&P.C.for this'reason PERMIT.ISSUING FEE O
73
Date: TOTAL FEE P3 0 IF / U
Signature t,HANGE ,i 13 CL
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT Z
I hereby affirm that I am exempt from the Contractor's License Law NAME . , y toy �+'��� 1/1-3/9'
for the following reason (Section 7031.5, Business and Professions !ll���-��� s k I—I
Code): ADDRESS "cC i ht 9:07
❑ I, as owner of the property, or my employees with wages 1\14C AA& r:tiv M
as their sole compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale (Section 7044,
/ Business and Professions Code). OWNER
I, as owner of the property, am exclusively contracting MAIL s
with licensed contractors to construct the project (Sec- ADDRESS.
tion 7044, Business and Professions Code). �.
CITY TEL:NO.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for CONTRACTOR
the performance of the work for which this permit Is issued pop(Sec.3097, Civ.C.).
ADDRESS
Lender's Name
CITY TEL.NO.
VlsLender's Address STATE LIC. '
I 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 County to enter upon t bove-mentioned
pro erty for inspection purposes.
'� _ ` SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APPLICANT OR AGENT DATE