HomeMy Public PortalAbout10552 LIVE OAK AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 20'-0046 DPW 9/89 (�o FOR
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76A364C APPLICA��®0tI Ir®W Ir�EWIIHII��a
I hereby affirm that•I have a certificate of consent to self insure,
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or a certificate of-Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec 3800 Lab C) ' ' ' '
Policy No� �� ompariv COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ ',Certified copy is hereby furnished" '-
Certified copy Is flied with the county building Inspection FOR APPLICANT TO FILL IN BUILDING ADDRESS
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( departure t T- (PRINT OR TYPE ONLY) •
Date Applicant 4r—` ` l rl� LOCALITY7--
- NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS ST
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
(This'section need not be completed if the work Involved by the MAP BOOK PAGE PARCEL
permit Is for one hundred dollars($100)or less.) - AIR HANDLING UNIT,CFM ,
DISTRICT NO PROCESSED BY
I certify that in-the performance of the work for which this permit
is Issued, I shall`not employ,any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws
" - COMPRESSOR BTU •� x ��� �' ��✓ /
- APPROVALS DATE INSPECTOR'S SIGNATURE '
Date Applicant VENTILATION SYSTEM
" NOTICE TO APPLICANT If, after making this Certificate of ROUGH ^
'Exemption,you should become'subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such A oeFINAL
provisions or this permit shall be deemed revoked FURNACE FAUGRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU o VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and WALL c
' Professions Code,and'my license is In full force and effect
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C� HI=:c:Teg
License Number, 6- a 7 Llc Class .9c
3103
0ContractorC-MF
❑ I am exempt under sec Plan check fee TOTAL J8 7® 6�
B&PC for this reason PERMIT-ISSUING FEE$ :HECK ' 137.b
DateCH GE
. •TOTAL FEE i
' Signature d
PLAN CHECK APPLICANT U)
IOWNER-BUILDER DECLARATIONI� tYU_)t'yl� t� i f�Z
I hereby affirm that.l am exempt from the Contractor's License Law NAME"[ ���L 'C8 D iV c7
for the following reason•(Section 7031 5, Business and Professions �C- 1�� PcY,
Coe) ADDRESS f.�- � . I'f7Y f 4- IvL.QN'� !r ?
,`I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY/s.�Q/`�.�I�• �A6 TEL'NO �-77
structure is not Intended or offered for sale (Section 7044, r
Business and Professions Code) OWNER!T `A♦ ��T�p/�
❑ I, as owner of the property, am exclusively contracting MAIL, cam[ NI <
wrth.Ilcensed contractors to construct the project (Sec- ADDRESS4�� S.• �LD&d� cST. Ni-qX
tion 7044, Business and Professions Code)
CONSTRUCTION LENDING AGENCY CITY-`eS r�- �� � TEL NO�2
I hereby affirm that there'work
CONTRACTORKG /V
a construction lending agency for X/,#
the performance of the work for which this permit is Issued ��'`'� ,QW/G4 n
(Sec 3097,Civ C)
ADDRESS,,/3,S' S F. :5,4N T
Lender's Name
CITY 1� TEL N037�jA",�
Lender's Address STATE LIC 1O
I certify that I have read this application and state that the above 16 LICENSE NO J Q CLASS
Information Is correct I agree to comply with all County ordinances
and State laws Wlating to building construction,and hereby authorize a
represent I of this'C unty to enter upon the above-mentioned
property ection urposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Ai'
SIGNATURE OF APPLICAN OR AGENT DATE '