HomeMy Public PortalAbout9462 LEMON AVE_Mechanical__ WORKER'S COMPENSATION^DECLARATION 76A364DPW9/69 APPLICATION FOR, PERMIT
LIME - GREEN
C
I,hereaffirm that,l have a certrflcate_of consent to self Insure, 76A364 '
or a certrficate of'worker's Compensation'Insurance„ora certified �'- HEATING,=„VENTILATING'=-AIR CONDITIONING
w• copy they ( 3 C) -�
00
I❑61icy It. CompanyCOUNTY OF LOS-ANGELES 'DEPT OF PUBLIC WORKS BUILDING'AND,SAFETY DIV. '
Certified copy Is hereby furnished
Cete o is filed with the coup building ms ection FORAPPLICANT TQ�FILL IN_', ADDRESS f�
tPY ri 9 P ADDRESS I `
c det-` , - (PRINT OR TYPE ONLY ,
' - ' - - - LOCALITY /
'Date Applicant 'n� �«
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
- NEAREST �f a
CERTIFICATE OF EXEMPTION FROM WORKERS' '' H , .•.
_ COMPENSATIONCROSS ST
ABSORPTION�” ABSORPTION UNIT,BTU f. r A• ,` _
ASSESSOR L;
(This Bel& need'not be`completed-d the,work involved by the `t MAP BOOK 5 PAGE' �." PARCEL
permit is for one hundred dollars(5100)or less.) AIR HANDLING UNIT,CFM
2 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,manner so as'to BOILER,BTU f
become subtect,to the Workers' Compensation Laws
e; COMPRESSOR BTUo
APPROVALS "' DATE "IN,SPECTOR 5 SIGNA,-
TURE, e
fi{Date'
Applicant = VENTILATION SYSTEM
tNOTICE TO APPLICANT If, after making this Certificate of ROUGH
�Exemp{lon,.you should'become,sub/ect to the Workers'Compensation, EVAPORATIVE COOLER
provisions of the Labor Code,,you must-forthwith'comply'wlth such - FINAL
provisions or this pefmrt shall be deemed revoked FURNACE .FAU GRAVITY
•LICENSED CONTRACTORS-DECLARATION FLOOR` BTU' VALIDATION ..
rl 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 _ yygLL
'Professions Code;•ana•my license,is'm;full force and'effect
-- ' ,,' a�:•, �qyy�//// ;may/� �. ,���. - ' •-' �,:; , < , - • `
License'.Numbei //� C��/ Lic Class =,
► .r. .8 a Hf't_�. s�t o
Contractolate'—
[
ate
❑, Pam exempt under Sec r Plan check fee !
p. 1',J EM�
B&P C for this reason PERMIT ISSUING FEE $ 52 05
}_
Date TOTAL FEE - Vic;52.0, .,LU
T ��HECK -
`"' - V'Signature .•: N i V)
PLAN CHECK APPLICANT CHANGE
', ,i�(_+ Z
OWNER-BUILDER DECLARATION „
I hereby'affirm that I am exempt from'the Contractor's License Law NAME
for the,following reason(Section 7031'5, Business-and Professions'
Code) ;i•c : ' , ADDRESS _ ' - �j �l^-�,��hl;, • •:.•�.{lr`'1_r -_'•
f
❑,
1,'.. owner of the property, or,my employees with wages % y ; t jy �., AM ''/. J2
as'their sole'compensation, will do the work and the CITY TEL NO"
structure Isnot Intended or offered for,sale (Section 7044,
Business and Professions Code) I IOWNER
❑ I, as owner,'of the property,,am'exclusively contracting. MAIL
with licensed Contractors to construct the project (Sec-, ADDRESS '
tion 7044, Business and Profes'sions,Code) r—
• CITY TEL NO - ,
CONSTRUCTION LENDING AGENCY ;
,I,hereby=affirm that'there-is a construction lending agency for ^ CONTRACTOR /// .,
„the•performance 'of they«work for which this permit Is Issued ,= ?. «,+r "
(Sec 3097,CIV C) , Nr
• ,;, ADDRESS - . - •�
Lender's Name
CITY TEL NO
'Lender's=Address STATE LIC`
'I certify.that'I have read this application'and state that the above LICENSE NO CLASS
t :Information is correct 'i agree'to comply with all County ordinances • `
r and State la4reing to bwldmg construction,and hereby authorizerepresent ithis County to enter upon the above-m rationed
propert fc 'n,purposesLANGUAGE' �{ e
�f SEE REVERSE FOR EXPLANATORY
SIGNATURE' F LI T R AGENT D E '' ,