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HomeMy Public PortalAbout10634 LIVE OAK AVE_Mechanical__ VQRKER76A364C'S COMPENSATION DECLARATION 20-0046 DPW,9/89 APPUCA�0®0V' FOR- PERM T V GREEN I hereby affirm that I have a certificate of consent to self Insure, or a certificate of Worker's,Compensafion Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING copy thereof(Sec 3800 Lab C) Policy No Company COUNTY OF LOS ANGELES DEPT OF.PUBLIC.WORKS BUILDING AND SAFETY DIV. ❑• Certified copy Is hereby furnished ❑ ' Certified copy Is filed with the county bulldmg Inspection FOR APPLICANT TO FILL•IN BUILD department " (PRINT OR TYPE ONLY) A LOCALITY Date, Applicant NO TYPE OF APPLIANCE OR EQUIPMENT FEE,. CERTIFICATE OF'EXEMPTION FROM WORKERS' „ NEAREST COMPENSATION^INSURANCE CROSS ST ABSORPTION UNIT,BTU ASSESSOR (This section need not be completed If the work Involved by the MAP BOOK PAGEPARCEL permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO PROCESSED BY certify that In the performance of the work for which.this permit Is Issued, I shall not employ any person in any mann o as to I BOILER BTU become subject to the Workers'Compense on Laws �d. _ COMPRESSOR BTU ' dAPPROVALS DATE INSPECTOR'S SIGNATURE Date �O Applicant Q141 VENTILATION SYSTEM NOTICE TO APPLICANT If, after making this Certificate of ROUGH Exemption,you should become'subtect to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code,you must forthwith comply with such FINAL - provisions or this permit shall be deemed revoked ~' / FURNACE FAU G V TY O D LICENSED CONTRACTORS DECLARATION, ( FLOOR BTU //� VALIDATION I hereby affirm that I am licensed under-provisions of Chapter 9 HEATER 'SUSPENDED. UNIT (commencing with Section 7000) of Division 3 of the Business^and WAL t 'Professions Code,and my license is In full force and effect , 1 • , 2 _^ r t o a. 'License Number �+�+ Lic Class LdO ` 7, . 00 Contracto r DateA&90 ❑ �3o I am exempt under Sec Plan check fee B&P C for this reason PERMIT ISSUING FEE$ O Date TOTAL FEE Signature' a PLAN CHECK APPLICANT CIS OWNER-BUILDER DECLARATION z I hereby affirm that I am exempt from the Contractor's License Law' NAME for the following reason (Section 7031 5, Business and Professions D - Code) ADDRESS r1i•G s a ; ElI, as owner of the property, or my employees with wages as their sole compensation, will do the work and the, CITY TEL NO 7 structure is not Intended or offered for sale (Section 7044, q3 TT ��ikn Business and Professions Code) OWNER F-, T, 1 i I C11� I, as owner of the property, am exclusively contracting MAIL '`� © //!1 ^ ^` II�!{^SL 6 1 100 with.licensed contractors to construct the protect (Sec- ADDRESS 3 �iC/ tion 7044, Business and Professions Code) CITY T L NO CHECK CONSTRUCTION LENDING AGENCY t: 11�i19f_E I}Il 13 I hereby affirm that there Is a,construction lending agency for• CONTRACTOR the performance of the work for which this permit Is Issued r (Sec 3097,Civ C) e ADDRESS i-. Lender's Name J/� '`/1IT�— ji,14� �f,{y�if' l'' CITY _ TEL NO 'QG�2S " i 4 AM J I., Lender's Address STATE LIC I certify that I have•read this application and state that the above LICENSE NO 13 CLASS -Information Is correct I agree to comply with all County ordinances and State laws relating to building construction,and hereby authorize represent fives of this unty to enter upon the above-mentioned prop r or inspect) ur ses SEE REVERSE FOR EXPLANATORY LANGUAGE 70 SIGNA E OF APPLICANT OR AGENT DATE ,