HomeMy Public PortalAbout9684 LIVE OAK AVE_Mechanical__ �. firm ilKt I'havCOMPENSATION DECLARATION 20-0046 DPW
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I her affirm that I have a certificate of consent to self insure,
or.a certificate of Worker's Compensation Insurance, or a certified HEATINGVENTILATING-AIR CONDITIONING ,
copy thereof(Sec.3800 Lab.C.) LI
Policy No. Company ' COUNTY OF, LOS ANGELES`'' DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
❑. Certified co is filed with:the'count building BUILDING y
copy y g inspection FOR APPLICANT TO FILL IN f0�� �J claI-. Aug.
department. (PRINT OR TYPE ONLY) „ ADDRESS
Date Applicant OCALITY .
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST, L
COMPENSATION INSURANCE CROSS ST. T
ABSORPTION UNIT,BTU pp
(This sec tion,;need'notbe completed if the work involved by the M PEBOOK b �a• PAGE II PAFCEL03 d
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I-shall not employ any person in any manner so:as to BOILER,BTU
become'subject to the Workers' Compensation Laws. p
COMPRESSOR,BTU Ott
Date
Applicant' APPROVALS DATE. INSPECTOR'S SIGNATURE
, pp VENTILATION SYSTEM '• '
NOTICE TO APPLICANT: If, after-making this Certificate of ROUGH Z, Z_
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. y FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION 1 FLOOR BTU 0 ✓�✓ �DO VALIDATIOI�I
I hereby affirm.that I am licensed under provisions of Chapter 9 HEATERSUSPENDED UNIT '
(commencing with :Section 7000) of Division 3 of the Business and .. WALL
Professions Code,and.my license is in full force and effect.
1 00
License Number, Lic.Class , O v e� L�
�. o
Contractor Date V
Plan check fee
0, I am exempt under Sec. O O Q
B.&P.C.for this reason PERMIT 1SSUING'FEE$ � 0
Dater TOTAL FEE D O d
1.
Signature (D
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT Z
I hereby affirm that I am exempt from the Contractor's License Law NAME
for the following reason,(Section 7031.5, Business'arid Professions D,.
Code): I; as owner of the property, or my employees with wages ADDRESS g q �s V J�w
as their sole compensation, will do the work and the ( CITY TEL.NO.
structure is not intended or offered for sale (Section 7044, t J ��+
Business and Professions Code);' OWNER {, _ _
D i r
I, as owner of the•property, am exclusively contracting MAIL '
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044,Business and Professions Code). I tc ti'f
CITY TEL.NO. N
CONSTRUCTION LENDING AGENCY l t. jyNGE-. ,UJ
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit Is issued CONTRACTOR
D t
(Sec.3097;Civ.C.). _~
ADDRESS •'� �f hfj l', E ;''I
Lender's Name
CITY TEL.NO.
Lender's Address STATE, LIC.- -
I certify that I liave read this application and state that the above LICENSE NO. CLASS
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
representatives of this County to enterupon the above-mentioned
property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
-(30�,91
SI'NATURE OF APPLICANT OR AG T —! DATE '