HomeMy Public PortalAbout5827 MUSCATEL AVE_Mechanical__ '`WORK R'S COMPENSATION DECLARATION 7S DD4s DPW 9i8s LIME G
. -' 7�3�C ' APPLICATION FOR PERMIT
I hereby affirm that,.) have a certificate of consent to self Ensure,
or a 4ertitiaate.of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.1;.) .
Policy No. %Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished. y ���]
F1 Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BDDRE UILDIs �� ! r v t�I�S�0. �.l
department. (PRINT OR TYPE ONLY)
LOCALITY
Date Applicant
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
NEARE
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
(This section need not be completed if the work Involved by the ASSESSOR
MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit vJ
is Issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws. t [ L
1 COMPRESSOR,BTU vIt 00
Date L ZS �y Applicant APPROVALS DATE INSPECTOR'S SIGNATURE
VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY /-�
LICENSED CONTRACTORS DECLARATION I FLOOR BTU Q (G� I VALIDATION
1 hereby'affirm that I am licensed under provisions of.Chapter 9 SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and HEATER: WALL
Professions Code,and myy�license is in full force and effffect.
License Number ` t1-Ol Lic.Class `'^ �� ��'� D(,l { 5 - '
{ � POO. a
1G.-3t-Qti
Contrectorg -� DS
C
❑
I am exempt underSec. 33393;
Plan check fee
�'"'""•' D
B.BP.C.for this reason PERMIT ISSUING FEE i 3 i ;I� H
Date: TOTAL FEE TOTAL 1 ® =r a
Signature CHECK 1.44. V,
PLAN CHECK APPLICANT
OWNER-BUILDER DECLARATION I u- r'
1 hereby affirm that I am exempt from the Contractor's License Law NAME
��� ��f
for the following reason(Section 7031.5, Business and Professions'
Code): ADDRESS
❑ I, as owner of the property, or my employees with wages ;.1j�j11�311-0 12/251�`r I
as their sole compensation, will do the work and the CITY TEL.NO. G 1-` 12
1 All `'�
structure is not intended or offered for sale(Section 7044, .4 `
Business and Professions Code). OWNER �t C,:�, ov
❑ 1, as owner of the property, am exclusively contracting MAIL . '�
with licensed contractors to construct the pro `
project (Sec- ADDRESS Q0 g$ W, ,Qg cAA1aS
.tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY T2 M �� L TEL.NO. g6- 'J763
I
hereby affirm that there Is a construction lending agency for CONTRACTOR CpN
the performance of the work for which this permit Is issuedLN �- tIQ
(Sec.3097,Civ.C.).
ADDRESS `), R0.X J q
Lender's Name CITY G(etj 4.K,. ` TEL.NO.q l y. Q I
Lender's Address (� /' 1 p�
I certify that I have read this application and state that the above LICENSE NO. I a` LIC.
lam"�V
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
pro f ins actio urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIAURE OF APPLICANT Ofl AGENT DATE