HomeMy Public PortalAbout10046 LYNROSE ST_Mechanical__ DECLARATI
WORKER'S COMPENSATION a certificate
of consent to 70-0046 DPW 9,69 APPLICATION FOR PERMIT LI E GREEN
76A364C
I he¢eby affirm that I have a certificate of consent to self insure,
or a certificate os Worker'slCompensation Insurance, or a certified HEATING -VENTILATING-.AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.) r
74
Policy Mo 6�! — ` /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 ADDR SS
department. (J/� J/✓ y•�M (PRINT OR TYPE ONLY) e s�
Date Applicant Y 'l�/ ''J LOCALITY �E !y V
- NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE CROSS
ABSORPTION UNIT,BTU ASSESSOR
(This section need not be completed if the work involved by the p C r nj �� / 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 /� P
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU
.. APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE'TO APPLICANT: If, after making this Certificate of ROUGH 7 �R•
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
LICENSED CONTRACTORS DECLARATION FLOOR _BT 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'efffect.
License Number a IF Lic.Class IecJP
a.
Contractor s y / r //,G,T/V Date 0
❑. I am exempt under Sec. Plan Check fee V
Q
B.&P.C.for this reason PERMIT ISSUING FEE .jl 0
ate:�� TOTAL FEE U
W
Signature ec A0-
PLAN CHECK APPLICANT i CD
OWNER-BUILDER DECLARATION 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 , IL
Cade):
❑ 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 Tn 3-2 I, as owner of the property, am exclusively contracting MAIL EM
r
with licensed contractors to construct the project (Sec- ADDRESS '•`E
tion 7044, Business and Professions Code). --
CONSTRUCTION LENDING AGENCY CITY TEL.NO. '_`Iii' ¢s(F
I hereby affirm that there is a construction lending agency for CONTRACTOR
the performance of the work for which this permit Is issued
(Sec.3097,Civ.C.). ,
ADDRESS s f I
Lender's Name ' `
CITY TEL.NO. iwLc._
Lender's AddressSTATE 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
proper for inspectip poses. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE ORYA LICANT OR AGENT DATE'