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HomeMy Public PortalAbout10562 LIVE OAK AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-W46 DPW 9/89 G�����(���0®� �®� Ir ERst111�� (� /�RUN „ . 76A364C mss/ , �� /(,-.,I hereby afhrm that, have a certrficate of consent to self Insure, ` or-a certificate of,Worker's Compensation Insurance, or-a certified HEATING-VENTILATING -AIR CONDITIONING copy thereof(Sec 3800 La lV Policy No ompany "COUNTY OF LOS ANGELES .,}DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. ❑ Certified copy Is hereby furnished e Certified copy Is filed with the count building Inspection FOR APPLICANT TO FILL IN BUILDING ''__,, Y 9 ADDRESS ' � `lam �� department (PRINT OR TYPE ONLY) Date } Applicant C-5W/^'-`T1 7*”"�' LOCALITY�- pL,�' C JJ- NO TYPE OF APPLIANCE OR EQUIPMENT FEE CE(TIFOF LXEMPTION FROM WORKERS' NEAREST CROSS ST COMPENSATION INSURANCE ABSORPTION UNIT,BTU' (This section need not be com leted if the work Involved b the ASSESSOR P Y MAP BOOK PAGE 'PARCEL permit Is for one hundred,dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO , PROCESSED BY , I certify that in the"performance of the work for which this permit is'Issued,,I shall not employ any person In any manner so as to BOILER,BTU become subject to the Workers'Compensation Laws COMPRESSOR,BTU �A©� f APPROVALS• DATE INSPECTOR'S SIGNATURE Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT If, after making this Certificate of ROUGH ANT' Exemption,you should become subject to the Workers'Compensation• EVAPORATIVE COOLER FINAL .1/ ;:I 1:i �' provisions of the Labor Code, you must forthwith comply with such ' °� provisions or this permit shall be deemed revoked FURNACE FAu Or, O� l,t ' LICENSED CONTRACTORS DECLARATION - / FLOOR BTU VALIDATION i y ifs I"hereby affirm that I am licensed under provisions of Chapter 9 HEATER , SUSPENDED UNIT TOTAL -i , r � (commencing with Section 7000) of Division-3-of the Business and WALL •g.a- 2 ® + -- Professions Code,and my license is In full force and effect f li.•I r,C 370 0 2 ��Ts ovTLt .7s. D : CHEC i •s LlcenseNumber LIc Class �:�ANGE °ILLI Contractor Jk-c/°{z�pN"°LSate r J ` O ❑ Plan check fee - 4 . Q000-0001 fir, J./9, U am exempt under,Sec B&P C for this reason PERMIT ISSUING FEE$ � .�+ � AN 5°5 O Date TOTAL FEE: _ CLW Signature r _ IL OWNER-BUILDER DECLARATION ' PLAN CHECK APPLICANT Z I hereby affirm that I am exempt from the Contractor's License Law NAME ICG for the'following reason (Section'7031 5, Business and Professions Code) - ADDRESS ❑ I, as owner of the property, or my employees with wages as their sole com ensation, will do the work and the CITY TEL'NO /y structure Is not p intended or offered for sale (Section 7044; -�/� l�Q�' Business"and Professions Code)' OWNER ❑ I, as owner of'tlie property, am exclusively contracting MAIL W ^ with licensed contractors to construct the project (Sec- ADDRESS �Y �T ���� , tion 7044•, Business•and Professions Code). ��` CONSTRUCTION LENDING AGENCY CITY LDS �vL ' TEL N0���1�iF I hereby affirm that there is a construction lending agency for CONTRACTOR �� �, �C D the performance of the,work for which this permit Is Issued C �'w/ L , _ r . (Sec 3097,CIv.C) ; ADDRESS5477 7A 4I—OR V Sr. *'I , Lender's Name CITY A TEL NO 5774 Lender's Address 1 I certify that I have read this application and state that the above LICENSE NO 6� 3 ' B CLASS +� Information is correct I agree to comply with all County ordinances and State la relating to buiIding'construction,avid hereby authorize represent v f this C my to enter upon the above-mentioned proper t or ecUon urposes S/ �� g SEE REVERSE FOR EXPLANATORY LANGUAGE' SIGNATURE OF APPLICA/ OR AGENT DAT , -