HomeMy Public PortalAbout8848 LONGDEN AVE_Mechanical__ WORKER'S,COMPENSATION DECLARATION 20-0046
6 36 PW 9189 � �������®^n ®� ��n n�
I hereby affirm that I have a certificate of consent to self insure, wl u�P INAE. OEM
of a.certificate of Worker's Compensation Insurance; or a certified. HEATING-VENTILATING-AIR CONDITIONING ,.
cop thhereof�(SSec. 3800 Lab. C.)
Po cy N0�7 `� �� Company COUNTY OF LOS ANGELES DEPT-OF PUBLIC WORKS BUILDING APID SAFETY DIV.
❑ r
Certified copy ishereby furnished.
❑ Certified copy is filed with the c unt b 'din inspection FOR APPLICANT TO FILL IN . BUILDING '
ADDRESS . �y
EpEnt. (PRINT OR TYPE ONLY) LOCALITY
Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE J
CERTIFICATE OF EXEMPTIO M WOdolved
RS' NEAREST
CROSS ST.
COMPENSATION IN U N E ABSORPTION UNIT,BTU
This section need not be completed if t wor b the ASSESSOR
( PY MAP BOOKS(� PAGE G�' •PARCEL
'permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM'
DISTRICT NO. s PROCESSED BY
I certify that in the performance of the work for which.this permit
is issued, I shall not employ any:persori in any manner,so as to BOILER,BTU
become subject to the Workers'Compensation Laws. '/p ° Q
COMPRESSOR,BTU `�' OO n,. ..
APPROVALS DATE � INSPECTOR'S SIGNATURE,
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the.Workers' Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL =2Z g
provisions or,this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION / FLOOR BTU .3 VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000) of Division.3 of the Business and HEATER: WALL
Professions Code;and my license is in full force and effect. 6D
License Number 06 5 Lic:Class �`
/Contracto v Date t O
❑ I am exempt under S 'Plan check fee f 03 ~� G°Lh
Q
B.&P.C.for this reason PERMIT ISSUING_FEE•$ ..�('. 1 -ITEMS o
Dater - 'TOTAL I AL d .W
TOTAL FEE
Signature r.i�I:z i 106,+05 D-
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT (n
I hereby affirm that I am exempt,from the Contractor's License Law NAME"
CHANGE
ANGE _
for the following reason`(Section 7031.5•, Business and Professions D.
Code): o ADDRESS
❑ I, as owner of the property,.or my employees with wages IVLaI�-#Jlii1 �f g. .3,
as their sole compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale (Section 7044, �y� I',
Business and Professions Code). OWNER "
❑ I, as owner of the property,`am exclusively contracting'
MAIL "a;
with licensed contractors to construct the project (Sec ADDRESS
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY' CITY TEL.NO.
I hereby affirm that there is'a construction lending agency for ONTRACTOR n�
the• performance of.the work for which this permit Is Issued ,g.
(Sec.3097, Civ.C.). it
ADDRESS,
0141' 9 d• y JD
Lender's Name �� a) V tYTlrJA.l 3 /9
CITY TEL.N .1/ -`r
Lender's Address STATE LIC.;
I certify that 1 have read this application and state that the above LICENSE NO. 6`,15 CLASS (/
information is correct. I agree to comply with all County ordinances
dState laws relating to building construction,and hereby authorize "
r re nta_tives of this County to enter upon the above-mentioned
p pe r inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
9-95
SIGNATo64 Ort APPLIC� OR AGENT DATE -