HomeMy Public PortalAbout10432 MILOANN ST_Mechanical__ WORKER'S- DECLARATION 76A DPW 9/a9 I APPLICATION. FOR PERMIT
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I h e affirrvi�at I have a certificate of consent to self Insure,
or.a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING 41 ,C DITIONING
copy thereof(Sec.3800 Lab.C.) ' r,
Policy No. 7 )9 FFSCompany '6� 7c (AIJ) '
Certified copy•is hereby furnished. COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
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❑ Certified copy IS filed with the county building inspection FOR APPLICANT TO FILL IN• BUILDING
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department. g � / Lai
(PRINT OR TYPE ONLY) LOCALITY —Eil (�,/
Date -" Pipplicant Q I j v- NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEARESTr.
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COMPENSATION INSURANCE CROSS
ABSORPTION UNIT,BTU -ASSESSOR
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(This section need not.be completed If the work Involved by theMAP BOOK PAGE PARCEL'
permit Is for.one hundred dollarp($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
1 certify that in the performance of the work for which this permit
Is Issued, I shall'not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws. ^^ J49Qp
COMPRESSOR,BT.0 �w
' APPROVALS DATE INSPECTOR'S SIGNATURE '
Date Applicant• VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you'should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL.
provisions or this-permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION / FLOOR BTU o VALIDATION
I hereby affirm.that•1 am licensed.under provisions of Chapter 9 �, HEATER, SUSPENDED) UNIT
(commencing with Section 7000)of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect.
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License Number Lic.Class .0--� u
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Contractor Date :S� 118._R(;
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Lam exempt under SPlan check fee ec. Q
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B.&P.C.for this reason Date: PERMIT ISSUING FEE$ DTI_
TOTAL FEE , .3. LIL
IL 1 30 C
Signature '
CHECK 1i�o 3MOWNER-BUILDER DECLARATION PLAN CHECK APPLICANT CHANGE
.003
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): ADDRESS Vtl�f —td§iV3 7�1cyE
❑ I, as owner of.the property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL.NO. 1,M - 7
97 AM 10 27
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
tion 7044,Business and Professions Code). CITY TEL.NO.
CONSTRUCTION LENDING AGENCY
1
hereby-affirm that there is a construction lending•ayenc.y,for CONTRACTOR N�. L� '�' ��
the performance of the work .for which this permit Is Issued
(Sec.3097,Civ.C.).
ADDRESS
Lender's Name
CnY TEL.NI�
Lender's Addressa
I certify that I have read this application and state that the above _LICENSE NO. LIC.
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information is corre I agree to.comply with all County ordinances
and State laws rel ng to b ilding construction,and hereby authorize ,
representative f this C my to enter upon the above-mentioned
property pection rposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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SIGNA E OrKPLICANT OR AG NT DATE