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HomeMy Public PortalAbout10550 LIVE OAK AVE_Mechanical__ WORKER'S COMPENSATION,DECLARATION 2001146 DPW 9/89nn ®� IIHII�� rM 76A364C - I hereby affirm thdAPP��CATP®NI I� t I have a certificate of consent to self�lnsure, ERudu _ LLYY„^^UUYY�� or a certificate of Worker's Compensation Insurance,or a certified HEATING-nVENTILATING -AIR CONDITIONING— copy thereof(Sec 3800 Lab C) ,�j, ,(�J f- CO Policy WNwe y�� Compan oo L /(��T#L? • " • „ ' UNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUIL'DIN_ G'AND SAFETY DIV. ❑ Certified copy is hereby furnished 'certified copy is filed with the count buildin ms ection' FOR APPLICANT TO'FILL IN BUILDING Y 9 P ADDRESS dep`artm nt (PRINT OR TYPE ONLY) Applicant'1. " ,Ii!'Trrk�f/ LOCALITY /✓/ ��' 'C.i Date '', NO' TYPE OF APPLIANCE OR EQUIPMENT, �;: FEE — NEAREST CE_R_TIFICATE OF EXEMPTION FROM WORKERS' CROSS ST �'C �l B�` �Z •, °• COMPENSATION INSURANCE? ABSORPTION UNIT,BTU This sectlon need not be'Com'Completed if the work involved"by the ASSESSOR ( P Y ,. a•r;',. MAP BOOK v PAGE � PARCEL, , permit Is for one hundred dollars($100)or less') AIR HANDLING UNIT CFM' ; DISTRICT NO' PROCESSED BY, I certifyitFiat;in.the performance of the work for which this permit „ � is issued„I shall not employ any person in any manner so as•to BOILER,BTU Q become'subject to the,Workers'Compensation Laws!/ ” COMPRESSOR,BTU APPROVALS DATE INSPECTOR.S SIGNATURE Date ' Applicant VENTILATION SYSTEM NOTICE TO APPLICANT'If, after,making this Certificate of w ROUGH Exemption,you should become subject'to the Workers'Compensation EVAPORATIVE COOLER - provisions of the Labor Code; you mFINALust forthwith comply with such ` provisions or this permit shall,,be deemed'revoked FURNACE_ FAU V �y LICENSED CONTRACTORS DECLARATION FLOOR BTU �V VALIDATION •I hereby affirm,that Lm licensed under'provisions of Chapter 9; -SUSPENDED UNIT „ ,-(commencing with Section 7000)`of'Division 3 of the Business and HEATER. WALL Professions Code,and my license is'in'full'force and effect {• /^ !3 OL 5 c 001 /O v License Number/� �7• Lic Class •�� ' `i'��s -303 ContractorkL�xG/6r�!!!/C-4ate �! j 4 �'.ITEMS 0 ❑ I am exempt under Sec Plan Check fee + -PERMIT ISSUING FEE$ IJTAE" I� 0O • B&P C-for this reason � ' CHECKI�.v Date TOTAL FEE , r /� ("WiNGE o of;'� Signature PLAN CHECK APPLICANT - - Z OWNER-BUILDER DECLARATION I hereby affirm,that I am exempt from the Contractor's License Law NAME/< �/ Qom./ 't �y 3 t 1/9f,7` _•_ for,the following reason (Section 703115, Business and Professions /�C ��m`�C f D tf11QIJ- I}� e/ j��` 'InC�, Code) ADDRESS /�r"� . G'..C.RAa7.. .sk!/ 00, 1 1 AM 5 :. ❑ I, as owner of the property, or my employees with'wages f v as their sole compensation, will do the work and the CITY' fw� TEL 'NO ,structure is not intended or offered for'gale (Section 7044, ` ' " "' -7 Business and Professions Code) OWNER , as owner of the property, am exclusively contracting ❑':, dV1 2 Twith-licensed contractors to construct the project'(Sec- ADDRESS ��( s a tion 7044, Business and Professions Code) her -CONSTRUCTION LENDING AGENCY CITY L � �� TEL NOAj — I' elb affirm-that there i3 a construction lending agency for r t,•f, th'e-performance of the work for which this permit is issued CONTRACTOR C � L ^CG"' > _ _(Sec 3097,Civ C% ) J57-y.• `, 1 , ADDRESS Q. S*YV 7-A- GL,#Je-�ST �Y Lender's Name _ CITY �I� L Bf� TEL NO Lender's'Address STATEL © LIC CLASS y20 I " I certify that I have read this application and state that the above LICENSE NO 6 information is correct I agree to comply with all County ordinances and State I' s lacing to building construction,and hereby authonze v represen of this 96uhty to-enter upon the above-mentioned propert f r ct gfpurposes SEE REVERSE FOR EXPLANATORY LANGUAGE S,/,dju -. SIGNATURE OF APPLIC NT OR AGENT TE - '•