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HomeMy Public PortalAbout10546 LIVE OAK AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 200046 DPW 9/89 ���������®� ®� ������ UME GREEN 76A364C I hereby affirm,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 38000 Lab C) u Policy No Am✓e- 0 0 any4'k01'0!j6fJ 0A6-LF_ COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING-AND SAFETY DIV. Certified copy Is hereby furnished Certified copy is filed with the county building Inspection FOR APPLICANT TO FILL IN BUILDING O v Merit A (PRINT OR TYPE ONLY) ADDRESS / �,� OA/C. AV-�-Date Applicant U'• SR 15�?f'NU NO TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY -rte M P L Cf Ty CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST J T(may ABSORPTION UNIT,BTU ASSESSOR (This section need not be completed if the work Involved by the MAP BOOK PAGE PARCEL permit is for one hundred dollars'($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO PROCESSED BY I certify that in the performance of the work for which this permit Is Issued, I shall not employ any person in any manner so as,to BOILER BTU Q become subject to the Workers'Compensation Laws COMPRESSOR,BTU 46 O APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT If, after making this Certificate of ROUGH Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code, you must forthwith comply with such FINAL: provisions or this permit shall be deemed revoked - FURNACE FAU , LICENSED CONTRACTORS DECLARATION / FLOOR BTU �v, VALIDATION 11 hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED UNIT (commencing,with Section 7000) of Dlvision'3 of the Business and WALL ` Professions Code,and my license is In full force and effect /2 1^�L Ts oUT TS �o License Number 493 0 7 9� Lic Class 2' �•I�� _ } K�� 1"��`H AN 1'c-t 1 D �t't'�°8 IL Contractor 00 QPlan check fee - U� • 22 25V I am exempt under•Sec " � B&P C for this reason PERMIT ISSUING FEE$ :5, U Date SignatureTOTAL FEE a:d' 1 ITEMS cL PLAN CHECK APPLICANT OWNER-BUILDER DECLARATION TOTAL 122 . 2.'-:Z I hereby affirm that I am exempt from the Contractor's License,Law NAME CHECK for the following reason'(Section'7031 5, Business and Professions nG !"!C'Cf{Ll�✓/ca L Gd DLG��'fr� 10_= Code) ADDRESS I2S IF 4.4r�lA GL%I�YI'L�4 Si t1'// CHANGE °00 I, as owner of the property, or my employees with wages as,their sole compensation, will do the work and the CITY AP-GAD 1 l4 A/.0p6TEL NO J('?rL,. 779 structure is not Intended or offered for sale (Section 7044, I I �f Ifj_��j�q L Business and Professions Code) OWNER tW 01 I, as Owner of the property, am exclusively contracting MAIL L�U?4 i nil °`I; with licensed contractors to construct the project (Sec- ADDRESS Lr LJ Cf r �(„f�'� S�r 410!T tion 7044, Business and Professions Cade) � c CONSTRUCTION LENDING AGENCY CITY ��� I�{NtTCij TEL NO hereby affirm that_there,is a construction lending agency for the performance of the work for which this permit Is Issued CONTRACTOR 14 C, IM EC HA^If1�A<— Gm D - (Sec 3097,Civ C ADDRESS 125-j_%�' si4,j%f4 CGA/e4 97 0I _. Lender's Name CITY ���f}t)/4 ar 6EL NO ��-7 Lender's Address I certify that I have read this application and state that the above LICENSE NO 3 7 © 7 CLASS Z� t Information is rAprrect I agree to comply with all County ordinances and State la w}}}}}}��Q��Q el Ing to buffing construction,and hereby authorize „ representa f this Coy to enter upon the above-mentioned property r ntion T777_,�;Lb SEE REVERSE FOR EXPLANATORY LANGUAGE SIONATU F APPLICANT R AGENDATE