Loading...
HomeMy Public PortalAbout9528 LIVE OAK AVE_Mechanical__ i -WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89 76A364C APPLICATION FOR PERMIT LIME GREEN:, I hereby affirm that [,have a certificate of consent to self insure, cm,a certificate of Worker's Compensation Insurance, or a certified HEATING--VENTILATING -AIR CONDITIONING copy thereof(Sec.3800 Lab.C.) Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. Certified copy is hereby furnished. ❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN !DDRESSfUILDING department. (PRINT OR TYPE ONLY) Date Applicant OCALINO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST CROSS COMPENSATION INSURANCE 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($100)or,less.) AIR HANDLING UNIT,CFM - DISTRICT NO.' PROCESSED BY I certify that in the performance of the work for which this permit is issued, I shall not employ any per on in any manner o as to - BOILER,BTU become subject to the Workers' Comp do S. e7 b COMPRESSOR,BTU �� l . Date r � A Iicant APPROVALS 'DATE NSPECTOR'S SIGNATURE PP VENTILATION SYSTEM NOTICE TO APPLICANT: If, after making this Certific of ROUGH Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code, you must forthwith comply with such FINAL provisions or this permit shall be deemed revoked. FURNACE: FAU zp4 GRAVITY !' LICENSED CONTRACTORS DECLARATION FLOOR BTU 23 2cS VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED—UNIT— (commencing USPENDED UNIT(commencing with Section 7000) of Division 3 of the Business and WALL Professions Code,and my license is in full force and effect. 5�-15`11 �1 24, 630 License Number Lia Class `�1'�� d COntracto_r'�1����) �7l.Y.b�te� ❑ I am exempt under Sec. Plan Check fee V B.&P.C.for this reason PERMIT ISSUING FEE$ -7,3 O Date: TOTAL FEE Ub ©ID LU Signature 0- PLAN CHECK APPLICANT CO OWNER-BUILDER DECLARATION Z I hereby affirm that I am exempt from the Contractor's License Law NAME , s`• _'. for the following reason (Section 7031.5, Business and Professions ry=; Code): El f v I, as owner of the property; or my employees with wages ADDRESS i ! as their sole compensation, will do the work and the CITY TEL.NO. structure is not intended or offered for sale (Section 7044, v?j s; °i3��_; '06 Business and Professions Code). OWNER ❑ I, as owner of the property, am exclusively contracting MAIL with licensed contractors to construct the project (Sec- ADDRESS a"s J G. f_ tion 7044, Business and Professions Code). "`•T'�`t•`�r ::+.I_, CONSTRUCTION LENDING AGENCY CITY TEL.NO.y — �?�U hereby affirm that there is a construction lending agency for TO v CONTRAL the performance of the work for which this permit Is issued 1 tb'Lo e (Sec.3097,Civ. C.). :`.'•? z ADDRESS?' LA11d r _.f i, `< Lender's Name a CITY TEL.q kS Lender's Address STATE I certify that I have read this application and state that the above LICENSE NO. Q� CLLASS information is correct. I agree to comply with all County ordinances ang to bui ing construction,and hereby authorize re"s ou to enter upon the above-mentioned pro ur es. SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATURE O APPLICANT OR AGENT DAT