HomeMy Public PortalAbout10558 LIVE OAK AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION76A3W�ilry
64C 46DPW9/89 APPUf��pTION' F®IN FERMI II
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I hereby affirm that I have a certificate of consent to self Insure, ,
or a certificate of Worker's Compensation Insurance, or a_certlfled HEATING-VENTILATING-AIR CONDITIONING
copy thereof
p(Sec
y.3�800�L b C) • u
Policy No �Dmpany- ���� COUNTY OF LOS ANGELES ' ' DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.,
FT Certified copy is hereby furnished
Ii1i/pV,J Certified co is filed with the coup buildinginspection FOR APPLICANT TO FILL,IN BUILDING
department py nn- s ,gyp/ (PRINT OR TYPE ONLY) -; - ADDRESS ,Q�� g /Y,� 04tt �
Date $ Applicant [. LOCALITY pL �/
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST L'
CROSS ST �L /►i 0�7Lr
r ti, COMPENSATION INSURANCE,. ABSORPTION UNIT,BTU
(This section need,not be completed if the work involved by the ASSESSOR.MAP
MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO PROCESSED BY •
I certify that in the performance of the work for which this permit
Is Issued, I shall not employ any person In any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws
COMPRESSOR,BTU m Y �r
_/ APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant , VENTILATION SYSTEM
NOTICE TO APPLICANT If, after making this Certificate of ROUGH A14
Exemption,you should become subject to'the Workers'Compensation r?'�
"Provisions of the Labor Code, you must forthwith comply with such EVAPORATIVE COOLER FINAL, I qflj_q�lv
provisions or this permit shall be deemed revoked 4 FURNACE FAU G
LICENSED CONTRACTORS DECLARATION FLOOR BTU 5 n VALIDATIONACCT.8
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED -UNIT i,wi
(commencing with Section 7000) of Division 3 of the Business and HEATER WALL 3303 1 ■1`
Professions Code,and my license Is m full force and effect • - I
13 r-- r.5 v7z4g `o y 11
I ITEMS a
License,Number✓/`n o I Lic Class 2 O COITAL 126® 5}
CHECK
a.
ctn• ` • 0Contraod"IU
Plan check fee CHANGE❑
1 am exempt under Sec Q
B&P'C.for this reason PERMIT ISSUING•FEE$ � � _ �
. 0000-0001 '6/ 1 r Y,, v
Date TOTAL FEE' ��y •�_W
Signature
00,70 1 ,lM"9•-.`7 CL
OWNER-BUILDER DECLARATION' PLAN CHECK,APPLICANT Z
I hereby affirm that I am exempt from the Contractor's Llcense„LawNAME C rf �C.H+Ov/C_ •�. D
for the following reason (Section 7031 5, Business and Professions _
Code) `-• '' ADDRESS
❑ 1, as own er of the property, or my employees with wages
�'��' T/8 CL��� `ST ��
as their sole compensation, will do the work and the CITY �pC,GTEL`NO
structure is'not Intended or offered for sale (Section 7044,
Business and Professions Code) OWNER T S � /Ba
F-1 I, as owner of the property; am exclusively contracting MAIL
with licensed contractors to construct.the project (Sec- ADDRESS d !,( 4,04t/ J77, W /
tion 7044, Business and Professions Code)
CONSTRUCTION LENDING AGENCY CITY los w ./.e_+�L=,�•. TEL NO(�/� (�j�
I herpeby affirm that there Is a construction lending agency for CONTRACTOR W D
the erformance of the work for which this permit Is issued r�4o0VA71V.;Ci9L• dr
(Sec 3097, Civ C)
ADDRESS/1 �. c� �T•� CL cST. �(�/
Lender's Name Cl
CITYI p TEL NOS74_���iA
Lender's Address STATE / - LIC
I certify that I`have read this application and state that the above LICENSE NO -3 Q CLASS
Information is correct I agree to comply with all County ordinances
and State laws I ng to building construction,and hereby authorize
representativ s o this Cou ty to enter upon the above-mentioned
property fo I coon pLifposes SEE REVERSE FOR EXPLANATORY LANGUAGE
srbY f3
SIGNATURE OF APPLICANT IDAT