HomeMy Public PortalAbout10721 MILOANN ST_Mechanical__ I e. '• VIlt3RKER'SCOMPENSATION DECLARATION 2D-0046 DPW APPLICATION FOR PERMIT L�IIAE GREEN
I hp� ;aff r;m that I haves certificate of consent to self Insure,-
. clr•aj%rtis of`Worker's Compensation Insurance, or a certified' HEATING-VENTILATING-AIR CONDITIONING
cc�'y thereof(Sec.'3800 Lab.C.),' LI
P❑olic ,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 BUILDING —;7e-97
department:, (PRINT OR TYPE ONLY) ADDRESS
LOCALITY
'•� Date Applicant
.'NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST /)<�st ���( wf
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. [//JO V
COMPENSATION INSURANCE ABSORPTION UNIT,:BTU
(This section need-not tie completed if the work involved by the ASSESSOR
' MAP BOOK PAGE PARCEL
t permit is for one.hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY
I certify that in the:performance of the work for which this permit
Is issued, I shall not employ any person in any manner so as toBOILER,BTU
me subject to the Workers'Comp ation Las
�� 4- COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE r
Date 1 Applicant' ; VENTILATION SYSTEM
NOTICE TO.APPLICANT: If, afte. making this Cert! of ROUGH ✓����
Exemption,you should become subject to the Wor ' ompensation EVAPORATIVE COOLER e
provisions''of the Labor-Code,you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU VITY bO VALIDATION
LICENSED CONTRACTORS DECLARATION FLOOR BTU IG 0 M2
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT.
(commencing with Section 7000)of Division 3 of the Business and WALL
Professions Code,and.my license is in full force and effect.
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License Number ® Lic.Class C~
Contractor'Ao'I J 6 Da 1 /p����r a
❑ V I am exempt Plan check feept under Sec.
B.&P.C.for this reason ' PERMIT ISSUING FEE$ C
Ir-
Date: TOTAL,FEE — C
Signature +/ U
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
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.I hereby,affirm that Lam-exempt from the Contractor's,License Law NAME t JL
for the following reason(Section 7031 t5,'Busines nd Professions , ACC!".n T
Code): i. ADDRESS- 3307 61 n�li I
ElI, as owner bf the property, or m mployees with wages �� I
'as their sole compensation, III do the work and the CITY TEL.NO. 1 1��M
structure Is not intended or fered for sale (Section 7044, a-td–a
Business and Profession ode). OWNERAr lI:�TA:
❑ I, as owner of'the roperty, am exclusively contracting MAIL CASH
with licensed tractors to construct theproject (Sec- ADDRESS ��
tion 7044.ONS TRUCTION LENDING/AGIness and Professions ENCY CITY `— �� L.NO. CHANGE • tt
1 hereby affirm that there is a constr tion lending agency for CONTRACTOR V
the performance of the work for ch this permit Is issued
(Sec.3097,Civ.C.). , 0000-0001 • 12/ 6/90
. ADDRESS °� � '
Lender's Name y��RESS �� f �vfZ 4333 1 PrI12: li
CITY . �/' TEL. .W / �
Lender's Address "` /� n/n
I.certify that I h read this application and state that the above LICENSE NO. "(/ LIC.',
(fit•/
information isrrect. I agree to comply with all County ordinances • ,
and State lav0s relating to building construction,and hereby authorize
representatives of this County to enter upon the above-mentioned
p party for,-P ct purpg es. SEE REVERSE FOR EXPLANATORY-LANGUAGE
�C//PPffCC p I-MIGINATURE OF APPLICANT OR E •• DATE ,