HomeMy Public PortalAbout9151 LAS TUNAS DR_Mechanical__ WORKER'S COMPENSATION DECLARATION 200046 DPW 9/189 APPLICAZ!"AI�;FOR PERMIT
76A364C LIME, GREEN.
I herby,affirm that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certifiedHEATING -VENTItAflNG-AIR CONDITIONING
Copy thereof(Sec.3800 Lab. C.)
Polio ' � cbrfip6ny �G� / ems , COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING'AND SAFETY DIV.
❑ Certified copy is"hereby furnished. .
Certified co is filed with the count building inspection 'FOR APPLICANT TO FILL IN BUILDING
PY Y 9 ADDRESS LAS
department. `(PRINT OR TYPE ONLY)
Dat0444
e��ApplicantLOCALITY
N0. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF,EXEMPTION FROM WORKERS' NEAREST:,
COMPENSATION INSURANCE CROSS ST: /VG LY
ABSORPTION UNIT,BTU ASSESSOR
(This section need not be completed if the work involved by the MAP BOOKPAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
,. I certify that in the.performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws. a •
COMPRESSOR,BTU
- --. APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM.
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH `l
Exemption,you.should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. . FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 ) SUDE
SPEND UNIT
(commencing with,Section'7000) of Division 3 of the Business and / HEATER: _ WALL
Professions Code,and my license is in full force and effect.. E"f•* a
.. - ' - 03
3 _I _fy ;}fit
License Number Lic.ClasqR4 C
I
] � EHICmo°
at l
ate IContract TOTA52 135
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I am exempt under Sec. Plan check fee t_,-�ECK _ry� (CO
B.BP.C.for this reason PERMIT ISSUING FEE,$, Lf C • .��(�F }
.:H�tL
Date: TOTAL FEE"
Signature PLAN CHECK APPLICANT 1100114 111 EI �J it Z
OWNER BUILDER DECLARATION'
qq •` a ryts
I hereby affirm that I am exempt from the Contractor's License Law NAME /,f,� � G r , _ 4i l�i 1. At M I=
for the following reason(Section 7031.5, Business and Professions
Code): ADDRESS
❑ I, as owner of the property, or my employees,with wages
as their sole.compensation, will do the work and the CITY /� TEL.NO p
structure is not intended or offered for sale (Section 7044, v/�
Business and Professions Code). OWNER
. ❑' ` 'I, as owner of the property, am exclusively dontracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS �. v)
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY A ^CbTEL.NO.e` ��(s
I hereby.affirm that there is a construction lending agency for CONTRACTOR / � ,
the performance of.the work for which this permit Is issued
(Sec.3097,Civ.C.).
ADDRESS
Lender's Name
CITY TEL.NO.
Lender's Address STATE LIQ
I certify that I have read this application and state that the above LICENSE NO. �6h 9 '✓ 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 the above-mentioned
:property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
r75`
SIGNATURE OF APPLICANT OR AGENT DATE • -