HomeMy Public PortalAbout8718 LONGDEN AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 76A346DPW9/89 APPLICATION FOR PERMIT
76A364C UME G .,
I hereby affirm that I have a certificate of consent to self Insure,or a certificate of Worker's Compensation Insurance, or a certified,r 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
BUILDING
❑ Certified copy Is filed`with the county building Inspection FOR APPLICANT INT TO IN ADDRESS
department ( �
• 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,rieed not be completed if the work Involved by the MAP BOOK PAGE•, PARCEL '
permit is for one hundred dollars($100),or less.) AIR HANDLING UNIT,CFM
I certify that in the-performance of the work for which this permit DISTRICT NO PROCESSED By
. ' t •
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 O LO
' APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the'Labor Code, you must forthwith comply with such FINAL j
provisions or this permit shall be deemed revoked FURNACE FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU A DATION
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 WALL
Professions Code,and my license,is In full force and effect
• License Number LIc Class
a
Contractor Date U
❑• , I am exempt under Sec Plan check f@@ ;
B&P C for this reason PERMIT.ISSUING FEE $ oro
Date TOTAL FEE U
LU
Signature (n
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT Z
I hereby affirm that I am exempt from the Contractor's License Law NAME A0� `/ D —
for'the following reason-(Section 7031 5, Business and Professions /° / A
Code) _ADDRESS ���C/ - z,, / t; i n ir '
I, as owner of the property, or m em to ees with wages
! 'v
as their sole compensation, will do the work and the CITY 1
structure is not intended or offered for sale (Section 7044, TEL NO /P)>
Business and Professions Code) OWNER ZA 111AI
f '
I, as owner of the property, am exclusively contracting MAIL ti„ , T6IAL 5 2 05
with licensed contractors,to'construct the project (Sec- ADDRESS /- G p/�/� ��l� tI --•
tion 7044, Business and Professions Code) 4f t"-_I'� �t n i iE
CONSTRUCTION LENDING AGENCY CITY / TEL NO J C Att GE I:l
hereby affirm that there is,a construction lending agency for CONTRACTOR D
the performance-of the work for-which this permit is issued
(Sec 3097, Civ C)_
t I•`a _
ADDRESS ill jl SI�—E_}I�ti f y. 1=i': -+{t',
Lender's Name
CITY TEL NO d aa '
Lender's Address STATE LIC -
I certify that I have read this application and state that the above LICENSE NO CLASS
Information Is correct I agree to comply with all County ordinances ,-
ana Stale laws Mating to building construction•and hereby authorize
representativ f this o enter upon the above-mentioned
pro y fo sp coon p it oses SEE REVERSE FOR EXPLANATORY LANGUAGE
/'SIGNATURE O AP CANT ORA DATE ,