HomeMy Public PortalAbout4700 F MILLER DR_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-OD46 DPW 91.89 A� PLICATIO.N. FOR. PERMIT
I hereby affirm that II have a certificate of consent to self insure, Lia "E. GREEN;
or a certifibate of'Worker's Compensatlon Insurance, or a certified, HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.380b Lab.C.) u
Policy Nodv���9� Comps COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS, 'BUILDING AND SAFETY DIV.
❑^ Certl ,�&A IsKereby Turn ed.
Qom, Certified copy is filed with the county building Inspection ' FOR APPLICANT TO FILL IN BUILDING/ // /�D
( department. p� (PRINT OR TYPE ONLY) ADDRESS? 4
Date �s •Aoplica,=_� � LOCALITY
NO.. TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' i CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
(This section need not be completed If the work Involved by the MAP BOOK PAGE 1.PA_RCEL.
permit is for one hundred dollars($100)or less.) II AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certifythat'in the performance of the work for which this permit
is Issued, I shall not employ any person in any manner so as to BOILER,BTU
become'subject to the Workers'Compensation Laws.
COMPRESSOR,BTU -2 ;L9Ot/ B�
' APPROVALS DATE INSPECTOR'S SIGNATURE
Date. ' Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this,Certificate of ' ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor.Code,you must forthwith comply with such FINAL `
provisions or this permit shall be deemed revoked. FURNACE: FAU R B� VAUL
LIDATION
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9, . •SUSPENDED UNIT
(commencing with Section.7000)of Division 3 of'the Business and HEATER: WALL '
Professions Code.and my license in full force and effect. '
D I
License Numbet2(s Lic.Class C 3
Contractorgl/� Date � D C
❑ Plan check fee
. I'am exempt under Sec. 13,, a
B.&P.C.for this reason PERMIT,ISSUING FEE$• /� k
Date: TOTAL FEE rJD U
Signature. (J
OWNER-BUILDER DECLARATION -PLAN CHECK APPLICANT G
.I.hereby affirm that'I am exempt from the Contractor's License Law NAME
•for the.following reason(Section,7031.5, Business and Professions U '
Code): ADDRESS
❑ I, as owner of the property,.or my employees with wages s
as their sole compensation, will do the work and the CITY •TEL.NO. F4137 98'°91J.
l
structure is not intended'or offered for sale(Section 7044,
';Business and Professions Code). OWNER ITEMS
❑ 1, as owner'of the•.property, am exclusively contracting MAIL. 1'L,TILt`m0
with licensed contractors to,construct the project (Sec-' ADDRESS
tion 7044,Business and Professions•Code). {'r1Eir�4 y',° 'LI
CITY TEL.NO�� Z/ ti
CONSTRUCTION LENDING AGENCY
Ihereby,affirm that there•Is a construction-lending agency for CHANGE °Oil
the performance of the work for which this permit Is Issued CONTRACTO ►, ,
{Sec.3097,-Civ.C.). OF
ADDRESS n
Lender's Name• 0000-0061 •9123/q i
NO.
L'ender's Address •• O 9140 L 'AM 1147
I certify that I have read this application and state that the above IL CENSE NO. :3 Z�j� CLASS Z�
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
propert inspection'purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF A LI R AGENT DATE '