HomeMy Public PortalAbout10153 LYNROSE ST_Electrical__ (2) WORKER'S COMPENSATION DECLARATION" 200046 DPW 9/89 /�I��p ���"fl'�®ftp f�®1� I��I�I�A��' LIMEGREEN ,
• .76A364C PCU' L� II 117 FOR I� If11YHE
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 thlyre0 ec 3800 Lab C)
Policy;No Company " COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑' Certlsted copy-Is hereby furnished ,-
Certified op -Is filed with the c ty bwldmg inspection,/11FOR APPLICANT TO FILL IN BUILDING -
artm t r, (PRINT OR TYPE ONLY) ADDRESS
Dat �AppllCant LOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
•
COMPENSATION INSURANCE ABSORPTION UNIT,BTU CROSS ST
(This^section need not be.completed if the work involved by the, ASSESSOR i
MAP BOOK i PAGE PARCEL
permit:is for one hundred dollars($100)or lase.) AIR HANDLING UNIT,CFM DISTRICT NO P OCE SED BV• '
I certify that In the performance-of the work.for,which,this permit
is Issued, I shall not employ-any person In any.mannenso as to BOILER,BTU `
become subject to,the Workers' Compensation Laws
COMPRESSOR,BTU s�O
000
Date Applicant I Z APPROVALS DATE INSPECTORS SIGNATURE; 1
VENTILATION SYSTEM
NOTICE TO APPLICANT If, after making this Certificate of ROUGH
Exemption,youtshould become subject to the Workers'Compensation EVAPORATIVE COOLER }
provisions of the Labor Code, you'must forthwith comply with such - FINAL
provisions or this permit shall be deemed revoked ` FURNACE FTU GRAVITY
LICENSED CONTRACTORS.DECLARATION. FLOOR BTU � VALIDATION -
I hereb affirm that I am'licensed under provisions of Chapter 9 , t
Y P P SUSPENDED UNIT
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(commencing with Section 7000) of Division 3 of the•Busmess and HEATER WALL
Professlons'Code,and my license Is In full force anted effect
c" // !//A//��
License
;mbernLIc ClasCs�1 _
Contrac ��--Date � - - --•- � - •.- _ _. d•
❑ t Plan check fee
=s
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I am exempt under Sec
B&P C for this reason " '' PERMIT ISSUING FEE$
Date TOTAL FEE �`7 y 'TENS ;BVI
'��I�I� IL �
Signature - ,,,
PLAN CHECK APPLICANT - : C
- OWNER-BUILDER DECLARATION - CHEC
_K �.g�i'e fg
I hereby affirm that I am exempt from the Contractor's License Law t
for the following reason (Section 7031 5, Business and-Professions NAME r „ D �- V NG •f'I 1
Code)
ADDRESS
❑• ],,as owner of the property, or my employees with wages
as their sole compensation, will do ttie work and the CITY TEL NO - IIf '
• structure Is not Intended or offered-for sale (Section 7044,
Busmess and Professions Code) OWNER ?~•_ r i r1i i 11 Fa?I
❑ I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS' L
tion 7044, Busmess and Professions Code) q
'CONSTRUCTION LENDING AGENCY CITY TEL NO
I hereby affirm that there Is a construction lending agency for !�
the performance Of-,the work for which this permit Is Issued CONTRACTOR (!
(Sec 3097, Civ C)'
ADDRESS
Lender's Name
CITY ' TEL
Lender's Address STATE 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 -
andState I relating to building construction,and hereby authorize
re
r sef this County to enter upon the ab e-mentioned "
p r Ins ctio urposes / SEE REVERSE FOR EXPLANATORY LANGUAGE
^\ SIGNATURE A Lir
OR AGENT