HomeMy Public PortalAbout10548 LIVE OAK AVE_Mechanical__ WGthat,I COMPENSATION DECLARATION
tto 76A348DPW9/H9 AI�"PUCAT�®IIV' FOR PERMT L�ME
GREEN
76A364C wl
I hereby affirm that I have a certificate'of consent to self Insure,
OC a certificate of Worker's Compensation Insurance, or a certified p` HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec 3�LabPolicy No � pany�L� iV �4� COUNTY'OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certdied copy Is hereby furnished
Certified copy•Is filed with the coup building inspection FOR APPLICANT TO FILL IN BUILDING
de artmmeent, ri g�Jp►/ a! (PRINT OR TYPE ONLY) , ADDRESS -
Date T Applicant �`-SWI$; or1T�Y11� LOCALITY �f—w DF L� t _
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS'
C OSSS T - #I gw 7"
- COMPENSATION INSURANCE ABSORPTION UNIT,BTU
(This section need not be completed If the,work Involved by the dSSESSOR.
MAP BOOK i PAGE PARCEL
permit Is for one,hundred dollars($100)or less.) AIR HANDLING ONrr,CFM -
I certa
ify that In the performnce of the work for,which this permit DISTRICT NO PROCESSED BY
Is Issued, I shall not employ any person in any-manner so as to BOILER,BTU
-become subject to the Workers' Compensation Laws � �r v
COMPRESSOR,BTU �Q��
' - APPROVALS - DATE INSPECTORS SIGNATURE
DateApplicant - VENTILATION SYSTEM
NOTICE TO APPLICANT If, after making this Certificate of ROUGH 3
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor'Code,-you must forthwith comply with-such FINAL
provisions or this permit shall be deemed revoked FURNACE FAU VITY,
LICENSED CONTRACTORS DECLARATION I FLOOR BTU 0 VALIDATION
1',hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED F UNIT ( 3
(commencing with Section 7000) of Division 3 of,the Business and HEATER WALL I-li:�•ToF,
Professions Code,and my license Is In full force and effect - ; .Z y
'f Ct,t, i
License Number v 1C Class L n 1 TTCt 1.:
�� �/ c M+// / D TOTAL 1 ® ? a
Contractor E ate 1 J t:O
❑ I am exempt under Sec
Plan check fee �� �yy y U
G CHANGE .i li, Q
B&P C for this reason PERMIT ISSUING FEE$ d O
' r
Date TOTAL FEE �' .J 03000-13001' it h/ 1/?4i W
Signature PLAN CHECK APPLICANT - }c 1 ,4;�_� (n
OWNER-BUILDER DECLARATION Z
r _
I hereby affirm that I am•exempt from the Contractor's License Law NAME kjC AJ5GW,4�/�a"� , `AJC
for the following reason (Section 7031 5, Business and Professions -v D
Code) c- �i51-11R4
w w
El
ADDRESS- I, as owner of the property, or my employees with wages 3J E -541V KA CLgst 4 ` 7r ll/
as their sole compensation, will do the work and the CITY ®,0/,pTEL NO S74 x.74
structure is not intended or offered for sale (Section 7044, I��� r� •'w ♦ ,(
Business and Professions'Code) OWNER
❑ I, as owner of the property, am exclusively contracting AIL
/ � �r
` ,with licensed contractors to construct the project (Sec- A DRESS/04r S. Ftowirg S. *4lv;:!;
tion 7044, Business and Professions Code)
CONSTRUCTION LENDING AGENCY CITY BS El rLy TEL NO_16) YF
I hereby affirm that there Is a construction lending agency for CONTRACTOR D
I
he performance of the work for which this permit Is Issued e �� iQ-/!�/ L. O.
(Sec 3097,Civ C) .1 c
ADDRESS/.)t S 5+57"-A CL�GJ T `
Lender's Name 7
CITY C"JA /b QGi TEL NO < 710 ?`
Lender's Address STATE LIC -
I certify that I have read this application and state that the above LICENSE NO �j f7 7 CLASS C �`
Information Is correct I agree to comply with all County ordinances IFy
and State'1 s relating to budding construction,and hereby authorize
represen t sof tIiEouun ty to enter upon the above-mentioned
proper r trposes SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF 1PPLI ANT OR AGENT DA1E/