HomeMy Public PortalAbout4700 H MILLER DR_Mechanical__ • WORKER'S COMPENSATION DECLARATION a 20.0048 DPW 9189 APPLICATION FOR PERMIT
E N
I hereby affirm that I have a certificate of consent to self Insure,. 76A984C L I E G R E 'i
or a certificate of-Worker's Compensation Insurance, or a certified
copy there��o��f//(Secp3800 Lab.C.) ! HEATING-VENTILATING-AIR CONDITIONING
Policy NoW %��3 Compan COUNTY OF LOS ANGELES DEPT OF PUBLIC;WORKS BUILDING AND SAFETY DIV.
❑ Certifies opy is h reby furnished.
Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN pDDRE3
dep ment. (PRINT OR TYPE ONLY)
Date Applicant. tx/1 yGL®�.��+ ' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY 7,
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU XSSESSOR
(This section need not be completed if the work Involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.)• AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
•I•certify that in the performance of the work for which this permit '
Is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws. ??COMPRESSOR,BTU BTU O GD
Date Applicant. APPROVALS DATE INSPECTOR'S SIGNATURE
PP VENTILATION SYSTEM .
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject tothe Workers'Compensation
provisions of the Labor Code, you must forthwith comply with such. EVAPORATIVE COOLER FINAL
provisions or this permit shall be deemed revoked. • - FURNACE: FAU GRAY TY ��6th VAI A -L
LICENSED CONTRACTORS DECLARATION FLOOR BTU
ION
I hereby affirm that I am,licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000)of.Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect. '
License Numb srLIC.Class
Contractor 5i; � Date 40151-?d^f2 V
❑' I am exempt under:Sec. Plan check fee
Cc
B.&P.C.for this reason PERMIT ISSUING FEE$ �r� ,S�j Q
Date: TOTAL FEE 9 a d
Signature PLAN CHECK APPLICANT Cr
OWNER-BUILDER DECLARATION
1 hereby affirm that I.am exempt from the Contractor's License Law NAME - I
for the following reason(Section 7031.5, Business and Professions
Code): ADDRESS
❑ I, as owner of the property, or my employees with wages fati i
as their, sole compensation, will do the work and the CITY TEL.NO. 3307y,'�Ij;
structure Is not Intended or offered for sale (Section 7044, �r
Business and Professions Code). OWNER Tr
�9�G�P2 €• L I I:t IJ
❑ I, as owner of the property, am exclusively contracting MAIL ;I I-AL 9� 90
with licensed contractors to construct the project (Sec= ADDRESS LL,, uu
tion 7044,Business and Professions Code).. CITY TEL. r
CONSTRUCTION LENDING AGENCY
I hereby affirm that there Is a construction lending agency for CONTRACTOR CHANGE ,(:I}
the performance of the work for which this permit Is issued '
(Seo.3097,Civ.C.). u
ADDRESS �dI`'0001 0/23/91
Lender's Name
C
Lender's Address STATE
'' 7:46
LIC. C ��
I certify that I have read this application and state that the above LICENSE No 7. CLASS
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
property foinspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
r
SMIUMIRE O•APPLICANT OR AGENT DATE IF