HomeMy Public PortalAbout10501 LYNROSE ST_Mechanical__ WORKER'S COMPENSATION DECLARATION 200046 DPW 9/89 ���������®� ®� ������ �� GREEN
76A364C ,
I hereby affirm that 1 have.a certificate of consent-to self Insure,
or a certificate of worker's Compensation Insurance, or a certified
,HEATING-VENTILATING,-AIR CONQITIONIUMG
t eof(Sec 3800 Lab C) �
o ` No C: Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS,—, BUILDING AND SAFETY DIV.
ElCertified copy Is hereby furnished "
' Certified co ,is filed with the,c' nt building Ins tion FOR APPLICANT TO FILL,IN BUILDING
CCCJJJ ADDRESS
ep mentpy r. y g P (PRINT OR TYPE,ONLY) '
Date' �l Applicant NO TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST ,
CROSS ST',
COMPENSATION INSURANCE- ABSORPTION UNIT,BTU
(This,section neenot be completed if the work involved by the ASSESSOR
d
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,-CFM MAP BOOK PAGE PARCEL
DISTRICT NO PROCESSED BY
I certify that in the performance of the,work for which this permit "
is Issued, I shall not employ any person,In"any manner so as,toBOILER,BTU
become.subject to the Workers' Compensation Laws
( COMPRESSOR,BTU o
Date ° Applicant> VENTILATION SYSTEM ¢ APPROVALS DATE INSPECTOR'S SIGNATURE
NOTICE TO APPLICANT If, after making this Certificate of ROUGH
Exemption,you should become subject to the.Workers'Compensation r
provisions of the•Labor.Code, you must forthwith comply with such EVAPORATIVE COOLER FINAL,
'19 11
provisions or,this permit shall be deemed revoked FURNACE FAU ' GRAVITY -
r LICENSED CONTRACTORS DECLARATION- VLI FLOOR BTU -ATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and HEATER WALL
Professions Code, and my license is In full.force and%/�e"fffect�/71/
License Number, 1� Llc CIasS"`___���Y�`� a�
Contractor Date'I
❑ I,am exempt oder sec Plan check fee V
r cc
B&P C_for this reason PERMIT ISSUING FEE$ OO
Date TOTAL FEE W
,•'� Signature_ -
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT z
'I hereby affirm that I am exempt from the Contractor's License Law NAME Bz
i for the following reason (Section 7031 5, usiness and'Professions = =
Code) ACC¢,a s
- ADDRESS'
ElI, as owner of the property, or my employees with wages wL(t
,,as their'sole compensation, will do the work and the CITY TEL NO 7
structure is not intended or`offered for sale (Section 7044;. y 1TI '
Business and Professions Code) OWNER _'t _ n—h
❑ I, as owner of the property, am exclusively contracting- I�I j�I``�. 59 � 00
MAIL cif G c,0 CIE!,
with licensed contractors to construct the project (Sec- ADDRESS 1 a �•t ,
tion 7044, Business and Professions Code)
CONSTRUCTION LENDING AGENCY .' CITY TEL NO i_i tL�
fit}E
I hereby,affirm that there Is a construction lending agency for 1 ® G
the'performance of the.work for which this permit Is issued CONTRACTOR
JA �
�''•
(Sec 3097, Civ C) �•y �
ADDRESS
IQ
Lender's Name t�
CITY TEL NO VI��+ i �(` C:;4°fi 4
Lender's Address STATELIC
I certify that I have read this application and state that the above LICENSE NO' CLASS
Information I correct I agree to.comply with all County ordinances
and State I s relating to budding construction,and hereby authorize
re t is County to enter upon h above-mentioned
pro f s rposes �JSEE REVERSE FOR EXPLANATORY LANGUAGE f-
SIG UR OF LC TOR AGENT DATE - - '•