HomeMy Public PortalAbout9627, 9627 1/2 LAS TUNAS DR_Mechanical__ WOKER'SCQMPENSATIONDECLARATION 20404 2D004tSDPW9189 APPLICATION FOR PERMIT LIME GREEN
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he,? that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified I HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.)
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Policy. Company /�fb COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
IL:7JI' Certified copy is h reby furnished.
❑ C. rtified co is filed with th buil in Ins FOR APPLICANT TO FILL IN BUILDING
d part ntPy g (PRINT OR TYPE ONLY) ADDRESS
Date Applica LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CE -TI'
OF EXEMPTION FRNEAREST
OM WORKERS' CROSS
COMPENSATION INSURANCE
ABSORPTION UNIT,BTU ASSESSOR
(This section need not be completed if the work involved by the MAP BOOK PA PARCEL
permit Is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU p
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU �B
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH 14-144
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
..provisions or this permit shall be deemed revoked. FURNACE:• FAU GRAVITY /
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect.
License Number, &S tf) Lic.Class
Contras: J C�L Date X D s C
❑ (.
I am exempt under sec. Plan check fee =
B.&P.C.for this reason PERMIT ISSUING FEE$ F — C
=•: -
Date: OTAL - LL
Signature 4
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT TOTAL
ITA 12�--a 35 C
1 hereby affirm that I am exempt from the Contractor's License Law NAME
for the following reason (Section 7031.5, Business and Professions , CHECK -s—`
Code): ADDRESS�ILr I_.�''A 1 E
1, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale (Section 7044,
Business and Professions Code). OWNER P L fi. Itii10-1[01 sr 224 f"
❑ I, as owner of the property, am exclusive) contracting P P Y. Y 9 a.MAIL
with licensed contractors to construct the project (Sec- ADDRESS _ C
tion 7044,Business and Professions Code). r
CONSTRUCTION LENDING AGENCY C TEL.NO.
I hereby affirm that there is a construction lending agency for CONTRACTOR ,
the performance of the work for which this permit is issued
(Sec.3097,Civ.C.).
lhLender's Name �► t ADDRESS '
CITY TEL.NO. !
Lender's Address STAT 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
and State laws relating to building construction,and hereby authorize
�2.1..ATUIRE'
enatives of t is County to enter upon the above- entioned
or inspe on urpos SEE REVERSE FOR EXPLANATORY LANGUAGE
F APPLICANT OR AgENT AT