HomeMy Public PortalAbout9518 LIVE OAK AVE_Mechanical__ " WORKER'S COMPENSATION DECLARATION 46 DPW 9/89 APPLICATION FOR PERMIT LI E GREEN,
' 76A3
Thereby affirm that I have a certificate of consent to self insure, 76A364C
or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING -AIR CONDITIONING
copy thereof(Sec.3800 Lab. C.)
Policy No. y Company S i f�7F COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
El Certified copy is hereby furnished.
^� Certified copy is filed with the co ty building inspection FOR APPLICANT TO FILL IN BUILDING
ADDRESS ) r
,de_partme (PRINT OR TYPE ONLY) / Llv_F sti
Date "/Z� `+/j Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMP79N FRA WORKERS' NEAREST 1_:'A40147_ Gr! i�,.!�
COMPENSATION INSURANCE CROSS ST. rJV!/
ABSORPTION UNIT,BTU ASSESSOR
(This section need not be completed if the work involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU d v
become subject to the Workers'Compensation Laws. _ !/
COMPRESSOR,BTU
APPROVALS DATE INSPE R'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH V/--
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER -
provisions of the Labor Code, you must forthwith comply with such FINAL --
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAV TY y
LICENSED CONTRACTORS DECLARATION FLOOR BTU d VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect.
License Number __Lic.Class
Contractor KaLz Date ~�
ElPlan check fee _:',`.• U
1 am exempt under Sec.
BAP.C.for this reason PERMIT ISSUING FEE$ ��' ?"" a `5'7)"`i� O
Date: TOTAL FEE � .s -2.90 '-i: W
Signature
PLAN CHECK APPLICANT 'yG �! is i? Z
OWNER-BUILDER DECLARATION w
1 herebyaffirm that I am exempt from the Contractor's License Law ' ;= €•"t "< —
P NAME H-it;,� tea•`t!;
for the following reason (Section 7031.5, Business and Professions
Code): ADDRESS
❑ I, 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 y '
❑ I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TEL.NO.
I CONTRACTOR
r`
hereby affirm that there is a construction lending agency for 'f
the performance of the work for which this permit Is issued A '
(Sec.3097,Civ.C.)'. I )'-C
ADDRESS S /C� A Avt_
Lender's Name
CITYTEL.NO. 9��ISgJ
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
and State laws relating to building construction,and hereby authorize
representatives of this County to enter upon the above-mentioned
prope for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
-/ -1�_
SIGNAT r
E OF APFfICANT OR A ENT DATE