HomeMy Public PortalAbout10118 LYNROSE ST_Mechanical__ WORKER'S COMPENSATION DECLARATION .20-0046 DPW 9/89
I hereby affirm that'I have a certificate of consent to self Insure, .76A364C AP nLICAT N FOR PERMIT
MI
T LIME,
GREEN
_
'
or a certlflcate'of'VWorker'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 flied with the county'bullding Inspection FOR APPLICANT TO FILL IN B ILDING
-department,,-,, (PRINT OR TYPE ONLY)' DRESS C e
Date Applicant LOCALITY /
y _NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS! NEAREST t
- CROSS ST
COMPENSATION INSURANCE ABSORPTION UNIT,BTU � '.. '
(This section need-not be completed If the work Involved by the ASSESSOR
permit is,
one,hundred dollars($1'00)or less) , MAP BOOK PAGE PARCEL
t AIR HANDLING UNIT,'CFM DISTRICT NO PROCESSED BY
:I certify,that In therperformance of`the work for which this permit _.
is Issued, I'shall not employ any person In any manner so as to BOILER,BTU
become subject to the Workeis' Compensation Laws ?}�
try e r ` COMPRESSOR,BTU
APPROVALS DATE, INSPE TOR's SIGNATURE '
Date �ppkcant' I VENTILATION SYSTEM ,
NO TO APP ICA T If, afteF m i this &r Ific'ate of ROUGH
Exemption,you should'become st b Vto�tlie Workers'Compensation EVAPORATIVE COOLER
" provision's of the Labor Code;,you must forthwith comply wrt
ns h.such FINAL
provisioor thispermrt shall;be deemed revoked" FURNACE FAU GRAVITY ,..,
LICENSED CONTRACTORS DECLARATIONFLOOR BTU VALIDATION
I hereby,affirm,that 1 am licensed under'provisions of Chapter 9 SUSPENDED = UNIT
HEATER •+
,(commencing with Section 7000) of Division 3'of the Business and WALL
Professions Code,Fand my license Is In full force and'effect
License Number LIB ClassA .
Contractor y��� s Date S L,�� <<1— 9 CCT8 i Q
❑; I am exempt under Sec y Plan,check fee �3 1
/ Q
'B 8P C for this reason - - '' '` - �PERMIT ISSUING FEE$ yL 73 '. I ITEMS .. O
Date —( . , TOTAL FEE TOTAL 71 - 25 iw
Signature CHECK ?1.,~. n-
't '• PLAN CHECK APPLICANT
R- ILDER DEC ATION, CHANGE .ULA 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 owne'r' the property, or my employees wrth'wages �►t�t�—r.►Vtti 1.,.�t+:f 7c'
as their sole`compensation, will do the work and the CITY TEL NO -33 AMID■3
structure Is not Intended or'offered,for sale (Section 7044, 717i66 7 1 AMID
Business and Professions Code)
❑ 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) Gf'
CONSTRUCTION LENDING AGENCY CITY O O TEL N O
I hereby affirm that there Is a construction lending agency for f ONTRACTOR
the performance of the work for which this permit Is Issued
(Sec 3097,Civ C)
ADDRESS i
'Lender's Name
CITY TEL N
Lender's;Address
I certify that I have read this apphcation'and state that the above LICENSE'NO CLCASS-
information is correct I agree to comply.with all County ordinances
and State laws relating to building construction,and hereby authorize C ZQ
representatives of this County to enter upon the above-mentioned
property for ins c'tion purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
2 .
DATE
GN R P ENT