HomeMy Public PortalAbout9452 LIVE OAK AVE_Mechanical__ " WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89
76A364C APPLICATION FOR,
A,hereby aftfl•ni that I have a certificate of consent to self Insure' LIM,E.'"GREEN
or aceruhcate of Worker's CompensationInsurance, or a certrfied' 'HEATING VENTILATING -AIR-CONDITIONING,
copy thereof(Sec 3800 Lab"C)
Policy No Z�/�t�L—J%/O,orilpany ':�V�dAl"0 G, j COUNTY OF,LOS ANGELES DEPT OF PUBLIC WORKS' BUILDING AND DIV.
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Certrfred copy Is hereby furnished
' h `" FOR APPLICANT TO FILL IN BUILDING'
Certrfied copy is filed with the•county building inspecuo ADDRESS
/• �; 'dep mens• , (PRINT IOR TYPE ON -
Date Applicant ^' LOCALITY
NO TYPE OF APPLIANCE�OR EQUIPMENT FEE
NEAREST
-CERTIFICATE OF'EXEMPTION FROM,WORKERS', CROSS ST
COMPENSATION;INSURANCE
.4 ,+ '-> :,... ABSORPTION UNIT;BTU ASSESSOR •• Y q +• '
` (This section,need not be co'mpleted,if.the work involved by•the f MAP BOOK PAGE PARCEL
permit is for one hundred dollars($,100)'or,less.) AIR HANDLING UNIT,CFM
certrfy;th at in the performance:of the work for which this permit` DISTRICT NO PROCESSED BV v
Is'assued,-I shall not employ any person in any manner so;as,to' BOILER,BTU " P}
.Come,
to the'Workers' Compensation'Laws °
COMPRESSOR,KU
�
� J..• - - ZAPPROVALS DATE INSPECT SIGNATURE
' -.Date " ' ' Applicant N IOST
' NOTIblf f6i APPLICANT If, after mekmg this Certificate of N YROUGH'
Exemption,you should become subject to•the Workers'Compensation
provisions of the-Labor�Code, you must forthwith comply with'iEVAPORATIVE COOLER t t 'FINAL i+
provisions or this permit shall be deemed revoked d FURNACE -FAU ' •"GRAVITY '
'LICENSED CONTRACTORS DECLARATIONFLOOR BTU
'1 herebyaffirm that I am licensed uride'r.provisions of'C
,licensed SUSPENDED'-' ^ 'UNI
(commencing with Section 7000) of Division 3 of the Business and HEATER 'WALL--13
Professions Code;,and miry lli�`c/e`n'see is in full force'and.effect _
••�nS4�4 '" ,/.•-/ //SCJ �( A _ ' - .+, s _k- m-:- ,'p - -__'• { ,-_ Y _` _�^ _- �,�'
`License Number �-CiC Class
CL
rContractor` [3 Date
I am,ezempt under Sec `y Plan check fee , " :, t -• '�
"B&P C for this reason PERMIT ISSUING FEE$ d tj' �• - O
TOTAL FEE b0_ W
Signature A z - 0-
PLAN CHECK APPLICANT- CO
` OWNER-BUILDER DECLARATION Z'
I hereby affirm that ram exempt from the°Contractor's License Law NAME �w n
for the'following-reason ,(Section 7031 5, Business and Professions;- �'r/ T' 1 , ' O 7•
'ADDRESS'! / *• o g.' u
I, a6.owner ofythe property; or my employeestwrth wages •'' �' i F7 i'�' , + .••,Q,:,
as their sole compensation„will do the work and the CITY" / TEL NO l ' �+{_{' `' 1, je Oki
structurellsnot intended or offered,for sale (Section 7044„
Business and Professions-6o") F;; OWNER
❑ i a '•'�'
I,!as owner,of-t'he property, am exclusively contracting- TOTAL 25 � bo'
MAILi` , ,c
ywrth licensed'contractors to construct the 'project (Sec- ADDRESS. %'}l!✓!� _ `
"tion 74 , Business and Professions Code ^ 1 L r t ,� -E-
i 04: ) CITY, TEL NO,
^ -fF� 25.'i3
CONSTRUCTION LENDING AGENCY " -
I hereby affirm that there is a construction lending,agency for
the,per for mance of the work for whi p CONTRACTOR - S
ch;thls permit' is Issued /�►7!N[ ,', ,', s ro;'
(Sq_°3097,CTd.0
'ADDRESS
Lender's:Name• �, .. h f-r,
' ^r u• CITY TEL:NO''�. .` r h -
7=s AM
Lender's Address STATE;� LIC -r a,
I certify that I have,read this application and state that the above` LICENSE NO CLASSr; 'x "�
Information is,correct I'agree fo comply with all County ordinances ;.
and State laws relating tolbuilding construction,and hereby authorize'
representatives of this C ty to enter,upon the above-mentioned, * $ ' bA - ' -:•z'
,property for 1pp Tt6in p poses •w. - w .�; ;+r
SEE REVERSE FOR EXPLANATORY LANGUAGE
W- �Ax
SIGNATURE OFA L•IC TOR A