HomeMy Public PortalAbout6275 IVAR AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION R RM
I hereby affirm that I had'e a certificate of consent to self APPUCAToON FO°" PE°"°"°��
insure, or a certificate of Workers' Compensation Insurance, HEATING _ VENTILATING _ AIR CONDITIONING
or a.eertified copy thereof (Sec. 3800, Lab. C.) 76A364C
20-0046 DPW 9/88
Policy No. - Company
.❑ Certified copyris 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. ADDRESS Q �V
(PRINT OR TYPE ONLY)
Date " Applicant LOCALITY
NO; TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST. (1=4e1y%_ 72-0,v-
0
0,v -
(This section need not.be completed if the work.involved'by ABSORPTION UNIT,.BTU DISTRICT NO. P CESSED B
the permit is for one'hundred dollars•($100),or less.),
AIR HANDLING UNIT, CFM
.I,certify that in the performance of the.work for which this VVV (Ty .
permit is issued,I shall not employ any I.person in any manner.
so as to become subject to the Workers';Compensation Laws. BOILER, BTU APPROVALS DATESP CTOR'S GNATURE
Date Applicant COMPRESSOR;BTU ROUGH,
i
NOTICE TO,"..APPEI CANT: If, after making this Certificate of. VENTILATION SYSTEM FINAL
Exemption, you should *,become subject to the Workers'
Compensation'provisions f the Labor Code, you must forth- EVAPORATIVE,COOLER, I T
with comply with such provisions or this permit'sholl 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 with-Section 7000)of Division 3 of the Business WALL.
and•Professions Code,and my license is in full force and effect.
CL
License Number Lic..Class D O
U .
•`Contractor Date ad
❑ I am exempt,under Sec. O
Plan check fee
B.&P.C. for this reason: PERMIT ISSUING FEE $ Z
r
Date
TOTAL FEE -..
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
1 hereby affirm that I am exempt from-the Contractor's License
•Law for the following reason (Section 7031.5, Business and
Professions Code):
I, as owner-of the property, or my employees with ADDRESS ". s '
wages as their sole compensation, will do the work and f (j :" 1 'fes i?i
• the structure is not intended or offered for sole(Section CITY TEL. NO. �•}_;
7044, Business and Professions Code). OWNER ITEMS
I, as owner of the property, am exclusively contracting
• with licensed contractors to construct the project (Sec- MAIL 25���
Tion 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCYHIELCK• 3•�!'f
CITY TEL. NO. -
I hereby affirm that there is a construction lending agency for' D C — p]J(!
the performance of the work for-which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name DC! 'P•= i Ir 3/15/91.
CITY TEL. NO. '
Lender's Address -I'.°fi 3 AM 9:J.Ft
I certifythat I have read this,a application and state that the STATE LIG. '
PF LICENSE NO. CLASS
above information is correct. I agree to comply with all County It
ordinances and State laws relating to building construction,,
and hereby authorize representatives of-this County to enter
u pa-the above-mentioned property for in pection purposes: "
r / SEE REVERSE FOR EXPLANATORY LANGUAGE
` ' 17
t
Signature of Applicant or gent Da