HomeMy Public PortalAbout5241 MCCLINTOCK AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 200046 DPW 9/89 APPLICATION FOR PERMIT LIME GREEN
A364C
I hereby-affirm that I have a certificate of consent to self insure, 78
or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(bec.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 filed with the county building Inspection FOR APPLICANT TO FILL IN ADDR G ^ZL m `,
department. (PRINT OR TYPE ONLY) BUILD
Date Applicant LOCALITY.'T-(FokL� 0 , e a'
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE {{
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. L(s(j
COMPENSATION INSURANCE ABSORPTION UNIT,BTU ASSESSOR
(This section need not be completed If the work Involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person In any manner so as to I BOILER,BTU ceeq
become subject to the Workers'Compensation Laws. Q D00,
COMPRESSOR,BTU 04,� ���
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER �(
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRA TY
LICENSED CONTRACTORS DECLARATION / FLOOR BTU OUb l VAL ATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect.
v
License Number Lic.Class '
v , G
Contractor Date (C-'
❑ I am exempt under Sec. Plan Check fee a
B.&P.C.for this reason PERMIT ISSUING FEE$
Date: TOTAL FEE67 &p LL
4
Signature U,
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT a
1 hereby affirm that I am exempt from the Contractor's License Law NAMEAQ
for the following reason (Section 7031.5, Business and Professions vr—C✓ �/►�t /t �� p /► ��' /�
Qodg): ADDRESS L-'1 1 V l l'.W r•— ` ;?t:.•i°a
I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL.NO.%gWW32 6-Alt
structure is not intended or offered for sale (Section 7044,
Business and Professions Code). OWNER 0 p� Ll�-' �ITI/i1 +1= j
❑ I, as owner of the property, am exclusively contracting _
with licensed contractors to construct the project (Sec- ADDRESS II 1r4� t
tion 7044, Business and Professions Code). CITY �Iapjv>t 0AqTEL.NO - CHECK "�t°,-j'
CONSTRUCTION LENDING AGENCY i T(.�_�� �sr - t — -
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
C13G, —1 1313 1 r'f c r'�1
CITY TEL.NO. q Ail
i,i 8
Lender's Address STATE LIC. J 1 1
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
Eknd State laws relating to Ing construction,and hereby authorize
res: is ount to enter upon the above-mentioned
r erC o�`iRsp es. SEE REVERSE FOR EXPLANATORY LANGUAGE
DATE
SIGNATUREOF PPLICANT R AGENT