HomeMy Public PortalAbout9534 LIVE OAK AVE_Mechanical__ DECLARAT
WORKER'S COMPENSATION
certificate
of consent to 76A346DPW9/89 APPLICATION FOR PERMIT LI E GREE,
76A364C
I hereby affirm that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified HEATING -VENTILATING -AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.)
❑
cy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished. q—Z
❑ . Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDINGADDRESS J 7 /
-12
department. (PRINT OR TYPE ONLY)
LOCALITY
Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
This section need not be completed if the work involved b ASSESSOR
( P Y the MAP BOOK � PAGE Q Cu PARCEL 17
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY ,
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers' Compensation Laws. ((//
,I[►' COMPRESSOR,BTU APPROVALS DATE NSP CTOR'S SIGNATURE
Date r u Applicant ' , VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL —/
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY VALIDATION
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect.
License Number Lic.Class ?
Ig.
Contractor Date , 0
❑ I am exempt under Sec. Plan Check f@@ O
B.&P.C.for this reason PERMIT ISSUING FEE$,,-7/-/
7
Date: — TOTAL FEE
I � `' d
Signature OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT Z
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 q yt :' F-;":
❑ I, as owner of the property, am exclusively contracting MAIL d, JV
_with licensed contractors to construct the project (Sec- ADDRESS L U2' en ',j.(I S_ .:L. :
tion 7044, Business and Professions Code). =- -;•,
CONSTRUCTION LENDING AGENCY CITY �� TEL.NO. Y ; ,r ,._ ;•
hereby affirm that there is a construction lending agency for
the performance of the work for which this permit Is issued CONTRALTO
(Sec.3097, Civ.C.).
ADDRES 1_4
1�51 v r
Lender's Name1 4%
CITY TEL.N - f'
17
Lender's Address
STATE LIC.
1 certify that I have read this application and state that the above ILICENSENO. (� 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
property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APPLICANT OR AGENT DATE