HomeMy Public PortalAbout6251 IVAR AVE_Mechanical__ - WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89 nn p � p�
I hereby affirm that I have a certificate of consent to self insure, 76A364C '^PPUC`^'��®NI FOR PERMT
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or a certificate of Worker's Compensation Insurance, or a certified HEATING VENTILATING-'AIR CONDITIONING
copy'thereof(Sec.3800 Lab. CJ '
Policy Nol ` *16.5 Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND'SAFET.Y DIV.
Certified copy is hereby furnished.
❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING
• department. .. �� �. � :• (PRINT OR TYPE ONLY) - - _ •.•. •. -
Date 2—_2 .-0/2r Applicant. �" � NO. TYPE OF APPLIANCE OR EQUIPMENT - FEE "-:. LOCALITY, e -
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS ST. - �®
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
This section need not be completed if the work involved b the ASSESSOR
( P y MAP BOOK ' J to PAGE_d/Q PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY ..
I certify.that in the performance of the work,for which this permit
Is issued, I,shall'not employ any person in any'manner so as to _ BOILER,BTU G
become subject to the'Workers' Compensation Laws.
COMPRESSOR,BTU 7 �, �G�^b r� O• i
_ APPROVALS DATE INSPE OR'S SIGNAT RE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If;.after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'.Compensation EVAPORATIVE COOLER
proyisions of the, Code, you must,forthwith comply with.such FINAL
'•,provisions.orthis permit shall be deemed revoked. FURNACE: FAU- GRAVITY
LICENSED CONTRACTORS DECLARATION / FLOOR BTU VALIDATION
'1 hereby affirm that,I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000) of'Division 3 of the Business avid HEATER: WALL
Professions Code,and my license is in full force and effect.
License Number vi' i/ Lia Cla, ,
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Contractors . /�`t f� !c,.Date"•jZ"-7J S 0
• ' I am exempt under Sec. Plan Check fee
B.&P.C.for this reason PERMIT ISSUING FEE.$ 0
Date V
TOTAL FEE f d
Signature 1 PLAN CHECK APPLICANT co
OWNER-BUILDER DECLARATION fl Z
m
I hereby affirm that I am exempt frothe'Contractor's License Law NAME
i
for the following reason (Section 7031,5,.Business and Professions' a
Code):' ACCT a 4'
ADDRESS i r �
�. I, as owner of the.,property or'my employees with wages 3Z'�j. 1't .
as their sole compensation, will'do the work and..the CITY TEL.'ND. i ITEMS structure is1 not intended or offered for sale (Section 7044, 'ITEMS.
Business and Professions Code). . _ OWNER ,d/.OS,,,.: TOTAL ' 1 3 R+50
[,-as owner of the property, am exclusively contracting MAIL' f/ CHECK
`V i ety
with licensed-contractors to construct the project (Seo- ADDRESS - / �.Y�G� `.f7El.r� _ 143.50
tion 7044, Business and Professions Code). CHANGE CONSTRUCTION LENDING AGENCY CITY jt�j�� .�-Ty TEL..NO: ( /QO2` CHANGE oOO
( )
theeperfoaffirm rmance of that e work foe is a rwhich construction
permit is issued p P � ed CONTRACTOR�°i/e�.�-fir/, /y jj•9L1��ya� ' -
Sec.3097,Civ.C.. 9�2 /�,, D
ADDRESS DO
�✓✓� lQ� r DO QQ0.1.i. 121-7/95
ADDRESS
Lender's Name _ .- / - 3642 :. 1.•_.... F7f I1V•�1 f
' CITY �v/�Y.�P4� TEL.
Lender's Address STATE LIC.� C ASS
certify that.I have read this application and state that the above LICENSE NO. ✓
-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
property.for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APPLICANT OR AGENT DATE -