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Home My Public Portal About4929 MCCLINTOCK AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 7OC APPLICATION FOR PERMIT DPW 9/89 n I hereby affirm tflat I have a certificate of consent to self insure, or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING III�� IIIJJJ u LLLIII LLL�� V LLL��LLL�� copy thereof(Sec.3800 Lab.C.) Policy No. Com 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 ADDRESS ��g BUILIJING de rtmen ` (PRINT OR TYPE ONLY) Dat Applicant. �� NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST CROSS ST. COMPENSATION INSURANCE ABSORPTION UNIT,BTU (This section need'not be completed if the work Involved by the MAPEBOOK PAGE PARCEL permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY I certify that in the performance of the work for which this permit 109 Is issued, I shall not employ any person in any manner so as to BOILER,BTU become subject to the Workers'Compensation Laws. (110 COMPRESSOR,BTU O-O APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT: If, after making this Certificate of ROUGH Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER - — ,r� provisions of the Labor Code,you must forthwith comply with such FINAL provisions or this permit shall be deemed revoked. FURNACE: FAU 1 !� it �� VALIDATION LICENSED CONTRACTORS DECLARATION FLOOR BTI L, I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT v� (commencing with Section 7000)of Division 3 of the Business and WALL Professions Code,and ddL�fmy license is in full force and effect. F)��•'_i o r� 77kLie. c - - 2 License Numbs .Class C Date ~s —�� ;IT .� — ... , ❑ Plan check fee _ �yj 7C I am exempt under Sec. CHECK ylw r'-All B.&p.C.for this reason PERMIT ISSUING FEE$ F rL-AL1,,G }. Date: TOTAL FEE a © a Signature OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 010,00-01,01.0h Y/ = 7E„"`§ I herebyaffirm that I am exempt from the Contractor's License Law tf 3 1 nx i`5X" P NAME , .t !-fit , o.},� for the following reason(Section 7031.5, Business and Professions Code): e): 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 ❑ I, as owner of the property, am exclusively contracting MAIL , with licensed contractors to construct the project (Sec- 'ADDRESS G tion 7044,Business and Professions Code). CI EL.NO. CONSTRUCTION LENDING AGENCY 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.). ADDRES Lender's Name PSTATE TEL.NO�g�5Lender's Address /L/G 7 r LIC..I certify that I have read this application and state that the above E N 7 T *- CLASS O 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( f r ins pectio/purposes. I SEE REVERSE FOR EXPLANATORY LANGUAGE I 1 E OFIAPPLICAA OR AGENT ATE