HomeMy Public PortalAbout9524 LIVE OAK AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89 APPLICATION FOR PERMIT LI E GREEN,
Ifiere$y affiim t6t 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. DC— O& Company St — FU t4 COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
® Certified copy is filed with the c my building inspection FOR APPLICANT TO FILL IN aooaEss /rP(,ZG
department. (PRINT OR TYPE ONLY)
Date
4—/
_9 Applican LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMP ON FR M WORKERS' NEAREST �^ A
COMPENSATION INSURANCE CROSS ST. ��(ytP(�� `-1 (�L1CI�
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($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws. J �_/� ,✓( �!/ J CiFlJvvlGll-��-�s
/ COMPRESSOR,BTU � 000 G
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH 7 /�
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU IT VLICENSED CONTRACTORS DECLARATION BTU � VALIDATION
FLOOR �7
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect.
TLicense,Number ��0� Lic.Class —
IL
Contractor Date V a:❑ Plan check fee a y r a _
I am exempt under Sec. _'{;k_ .1 _ -
B.&P.C.for this reason PERMIT ISSUING FEE$ N 76
Date: A
TOTAL FEE Q '"`''-» U
::i3 ,:si f'i[ LII
Signature D"'
PLAN CHECK APPLICANT co
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): ... .; -
❑ 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
❑ 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 hereby affirm that there is a construction lending agency for ONTRACTOR — /.._{ � 2t♦—_ ,
the performance of the work for which this permit Is issued, ¢ �
(Sec.3097,Civ. C.).
ADDRESS ` — S
Lender's Name
CITY _ f�../1 TEL.NO.�
Lender's Address
I certify that I have read this application and state that the above LICENSE NO. '`koil LIC.
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
propert r inspection p ses. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATUr OF APP CANT OR AGENT DATE