HomeMy Public PortalAbout10560 LIVE OAK AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 200046 DPW 9/89 ������'A`T�®nn ®� ��Bq ��
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I hereby affirm that I,have a certificate of consent to self insure, E
WE AREN' '
ona'certiflcate of Worker,s'Compensation Insurance, or a certified ., ; ` ' �,. ,HEATING-'VENTILATING`--AIR CONDITIONING -
copy•thereof(�Secce 3800
Pohcy No ompany COUNTY OF.LOS ANGELES DEPT'OF PUBLIC WORKS s - BUIL-DING'AND SAFETY DIV.'
' Certified copy is hereliy,furmshed'
Certified'co is filed with count building Inspection FOWAPPLICANT TO FILL IN's BUILDING
PY Y 9 P ADDRESS �� n - L l
departure <.,•t •, ', •• (PRINT OR TYPE ONLY) 4•
bate _ Applicant :C• .SRISAW / LOCALITY 7 x"pL�` .'L' �
., NO TYPE OF APPLIANCE OR EQUIPMENT, FEE
NEARE
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST
COMPENSATION INSURANCE ABSORPTION UNIT;BTU ASSESSOR Y'
(Thls.section need not be completed if the,work Involved by the MAP BOOK PAGE v` PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING.UNIT,CFM ` --- -
DISTRICT NO !� PROCESSED BY f
I certify•that in the performance of the work for which this permit
is•Issued, I shall n'ot:employ any person in any manner so as to BOILER,BTU
become subject to-the'Workers' Compensation Laws //.•�i
COMPRESSOR,BTU
APPROVALS '"' DATE INSPECTOR'S SIGNATURE
Date ti' Applicant VENTILATION SYSTEM '
NOTICE!TO APPLICANT If,',after.making this Certificate of ROUGH
Exemption,you should become subject to the'Workers' Compensation '
EVAPORATIVE COOLER ', ,'
FINAL
, provisions of the'Labor Code, you•must forthwith comply with such p `, -17•' '
provisions or,this permit shall be deemed revoked FURNACE FAU - R : '
-LICENSED CONTRACTORS DECLARATION FLOOR BTU — L - VALIDATION
I hereby affirm,thaf I am licensed under,provisions of Chapter 9 HEATER'S, "SUSPENDED UNIT a ;
(commencing with Section 7000).of Drvisiori 3 of the Business and WALL
Professions Code,,and my license'is m'full'force and effect '
LiceensNumber v�' Lic Class
e T•
4 D 330
Contractor toate' `�" � i•J
Plan check fee I'_ITEM'S V
❑ •I am exempt under Sec- '
B'&P C'for this reason ; PERMIT-ISSUING FEE$ £ TOTAL a 12-e -?F*'O
Date TOTAL FEE _ CHECK: 122`.25 W
4. d
Signature - HANGE - �t(I a-
PLAN CHECK APPLICANT K t CO
-OWNER DECLARATION Z
I hereby affirm that I am exempt from the Contractor's License Law NAME /�G �Gr4WI .L''
for the followingreason Section 7031'5 Business and,Professions'
( ... . r
Code)' ADDRESS�.Z S/:,0(1/
(l ff�,';�yy� to
I,'as owner of the property, or my employees with wages VV 71 AN, 9-+E_,
as their=sole compensation,.wlll do the work and theCITy , ���/ TEL NO ST�/-�7�� �"•
structure Is not Intended or offered,for sale (Section 7044, wV+�� - yr
Business and Professions•Code) ," OWNER
DI, as owner of,the'property,.am exclusively contracting MAIL
t , with licensed contractors to construct the project (Sec• ADDRESS
tion 7044, Business and Professions Code) `�
-' CONSTRUCTION LENDING AGENCY CITY � +J TEL N �I� /I a
1•-hereby affirm that there is a construction lending agency for D
the performance of the work for which this permit is IssuCONTRACTOR
ed
(Sec 3097, Civ,,,C) 4
ADDRESS zT-
i �� s ersr
Lender's Name
CITY J ` OOGTEL NO'51���,•
Lender's Address STATE2 LIC
CLASS
I certify that I have read tfiis application and state that the above LICENSE NO v
information is correct'It agree to comply with all County ordmances
and State I latmg to budding construction,and hereby authorize r` .
represen i s this ounty to enter upon tfie above-mentioned t
propert f Insp o rposes SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APPDC NT OR AGENTATY - ,