HomeMy Public PortalAbout10631 LOWER AZUSA RD_Mechanical__ WORKERS COMPENSATION`DECLARATION 20-0046'DPW 9/89;` •
' -
.,o �"
,.;,. w :.,, , - - 76A364Gw �.`r ,..'r t." . , ' ' 'G,��# k NY`
,.a.,, ',...- I '- "�`
I .,e eby a 1 rm that I have;a certificate of consent,to self insure,,° t,• 4_ CAT I£O�4PPL1 N F®R >P�RIVII,, I—.I ,. .. I . ., � �� � '
or ar•cerfficate of<Workec's Compensation Insurance or a:certihed " HEATING=VENTILATIRG ,��R;Cpyp�T�pN�NG +i :»_.
copy thereof(Sec:3800`Lab.CJ �"� z=' i i
f(/1,G'70fo�D i r0/7 X51.. r, . ,:' Sys `L a
G cyrNo: Company CQUNTY17�;OF LOSANGEL'ES 'DEPT OF„PUBLIC WORKS BUILDING ANDSAFETY,DIV 4 �% ':
. 11 I •$
Certified copy is herie y4furnished tS }
' ., •s
BUILDIIVGr 'yc:I°
:
I,.. Certified co Isfiled'witfi,the count •buildin ins echo,"t '°FOR APPLICANT TQ'FILL IN. { ;; F w ;.-,'
PY Y, 9 P - ADDRESS, 11
4'°department !' '• t - T OR TYPE ONLY) !-
x :i�:J,,.: ,ti ,” ;. �, i tt3 + 1. /LOCALITY• ��' - ¢"' h..
(PRIN
f F
Date y Applican NT *'
11;
..T •� .,,. , a
NO TYPE OF APPLIANCE OR EQUIPME FEE '' - fi.`.
}
a .. " ;NEAREST_,`,' c
3
CERTIFICATE OF EXEMPTION'FROM WOR S ,• ❑ x„ c� �t
4a .-, ,
,i
;t COMPENSATION,INSURANCEw'
=c <. ..,, - `• o ",." �ABSORPTIONUNIT,'BTU ar'�
CROSS ST.
AS -1 111
(This"section;;need'not be;completed,if;he:;work involved•,tiy.the; -' ,; ' * iMAP BOOK a,t P.AGE T PARCEL t
permit rs for-;one hundred dollars Of less) s qIR HANDLING°UNIT;.CFM h �,�i "
.v_e ,fl .,'- i „,; :.:. ., ,.t.: ,..: - DISTRICT NO. F`.R PROCESSED 9Y �. '�,,
I;certify",that,in the. erformance of'the:work•;for which,this' ermit `, ,-„"` n'. * r s; s_.
� ,,- P PI 1, t
is;issued, I shall not=employ.,an'y person in�any manner so as:to -,',• ."BOILER;BTU - _ r y r
y ppp
tiecome°sutiject to•the Workers'.Compensation•Laws / DU w
.<.. - - 'a e �'
x s, _11 COMP,.RESSOR,'BTU s X. ,
J. S . = -n S,�' t NSPECTOR'S SIGNATURE a;.,
.tn. , , ''
',i•, -,.. ,APPROVAL DATE GI
Date .c,, A" .., A licant 4...,,
PP ",. ' VENTILATION SYSTEM
NOTICE TO'APPLICANT slf;.a!ter'ma'kirig,'this Certiificate,,of,, 1. ROUGH , ;;
Exem tion,+ ou`,shoulii`becomeaubject'tosthe Workers'.,Coinpensation ' fi"" "`
P Y,; EVAPORATIVE COOLER,_ ,�iA
provisionspof,the Laboi Code,yo u'must',forthwith comply withsucli- 11 ' ` ,r-:, „ -° ."tU
F ,'provisions•or-this permit,shall be"deemed,revoked. ^` ", -,F,URNACE ;FAU GRAVITY+ ��a - 7 ..(, +
LI6' SLD CONTRACTORS DECLARATION � = FLOORr_. L 'BTU` 4, VAGDATION
FINAL -
1.
Thereby'affirm that) ani'licensed under provisions of.'Chapieir 9', ` • .' ” SUSPENDED-' UNIT" g' i `rt
,,., - .. -. HEATER:' - - ,,,a
(commencing,withrSecpon,7000) of Division 3;of;,the Business and WALL °
Professions Code,and my Jice'rise is m;full force and effect. ,
a
r u rr
e ' '�!' w'Nf 5 �� S 3 h t ." 41
License Number •' �� •r a 3Lic Class s p{'a `
Coritractor Date1. { . .O
�- Plancheck fee =U
I am exempt under Sec t r -n
B&P,C for this•reason. '� � t ,t ;f PERMIT ISSUING•FEE$ O� t; < `�'
r t ,a. ,+" a _ "Z. , t r 31St tJ "� ''
q
%
b Date :� , TOTAL.FEE ,M � ,',IUB;
t $ �- r a i i i t
't+ cwt ` a..
Signature as s
k.^_ '• "s. k%;. ".`�' -•- PLAN CHECK APPLICANT : ' r - ^� y .r„
`� OWNER-BUILDER DECLARATION ' r " ,j, - b
r: `� _
hereby affirm that'I,am exempt'from the Contractor s License Law ,¢ t-, -11.` k'n'
.t , ,.. ...,,.K._ .,... vK
t
NAME '
,Jpr.the following,reason'(Section 7031:':5,;Business and PFofessions:_a i
-:Code)10 S• ,,,5+ ' ADDRESS 19�- n F 1.s• I ;, ' ;' i.' \r I '�+ rl: !A—I ?
n. I a; caner of the. ro,ect or m em"lo ees:withi es "' = zr y '
', s o P. R_ Y., Y, P. y g11 s
as`their sale com ensation';will.'do the work•and the' CITYP. 4 TELlr. .NO <: "' =_,>d`
structure Isnot intended or offered".:for^sale (Section,7044 F11 — ,, ' -
Busmess and Professions Code).,,; ,� OWNER; �, Y4 �I .
;;vM I as,;owner'oVthe•property,,am exclusively-;contacting;.x �- v s
,.: W MAIL i w v K
with,,Iicensed,contractors to construct-the'proj'ect(Sec- -ADDRESS:.'. '
' ,, „
.,. y' ta✓h r,
T r,
tt
+ tion 7044,eBusiness grid=;P.rofessions Code). ". `,
. 11gra .. .;..:-r..<:: a -ti. ?. CITY< >'; TELzNO i +x, ..• t x •rt . ,t �. E £
e �•.��• -'r"' CONSTRUCTION LENDING AGENCY °}, ' r -,r; '`�3 {
,< r
-", { f
I hereby affirm that-there is,a construction lending agency for� r - n� f ti'
F .
h,the'pe'cformanceof the work fof'which this permit is issued CONTRACTOR — r i
(Sec 3097;"Civ C
Y1.. 4, 1. k}" ;� '
? t y 3�
4' d
ADDRESS �(-..�+
Lenders Name " • '" t�ILI n 1
4 1
1. GITY' U', 0� 0. s e
�" S J re 1 D
t Lender's Address
STATE - G '`r LIC.-,p r �. - s,:. s •u°`t we ,: t a
I;certif tfiat;l have read,this'a ,lication and state that'the above:
Y, PP LICENSE NO {CLASS C. i W
it5formation=is correct I a-iee totcom I with aWCount ordinances
,rla 9 , p Y,• Y. ,, a ; b
arid,Stat''laws relating.to building construction;'and.heretj'y'authorize. ,
rep"resent,tides;of this Couri11 i ty to'eriter,tipon the above,-mentioned ,,; , , i
may,.
pto'pert'y for 'nspectioti purposes -. " f 5
4SEE REVERSE FOR EXPLANATORY LANGUAGE'
,jL • �: - - -
'�S N T PPLI RrAGENT:, '�'] D E "' -
` 1