HomeMy Public PortalAbout4959 MCCLINTOCK AVE_Mechanical__ WORKER'S60MPENSATION DECLARATION ;� DPW 9189 APPLICATION FOR PERMIT LIME GREEN:
I 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 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.
❑ BUILDING
Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN ADDRESS
department. (PRINT OR TYPE ONLY)
LOCALITY
Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE -
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
(This section need not be completed if the work Involved by the ASSESSOR
MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY
I certify that In-the performance of the work for which this permit
is Issued, I shall not employ any person-in any manner so as to °I BOILER,BTU �I O
become subject to the Workers'Compensation Laws. �`,4
COMPRESSOR,BTU OfiQ
• APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM ,
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
.Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,.you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GR I 1-2141—
LICENSED CONTRACTORS DECLARATION FLOOR BTUD ' ULk"
1 hereby affirm that 1 am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect.
i
License Number LIC.Class _UG' ,, ��
�
a
Contractor Date C
El am exempt under Sec. Plan check f@@ '� a
C
BAP.C.for this reason PERMIT ISSUING FEE$ 5 F
Date: TOTAL FEE LL
Signature a
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT U
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): I '
ADDRESS ,y'.:t.I ,v
❑ 1, as owner of the property, or my employees with wages __a _ „(.e
as their sole compensation, will do the work and the CITY TEL.NO. r
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 i IJ I 7;-%
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITYAgle- TEL.NO. ,d73 7
I hereby affirm that there is a construction lending agency for N1111'. t•E'i=�14�4� ° t>
the performance of the work for which this permit is Issued CONTRACTOR ��yr el �1/
(Sec.3097,Civ.C.).
ADDRESS
Lender's Name
CITY TEL.NO. ter++
Lender's Address
I certify that I have read this application and state that the above LICENSE NO. CLLASS
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 eDter upon the above-mentioned
rty f inspectio poses SEE REVERSE FOR EXPLANATORY LANGUAGE
NA` DATE
i