HomeMy Public PortalAbout5941 MUSCATEL AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89 APPLICATION FOR PERMIT LI E GREEN
76A364C
I hereby gffirIn't4at''I tlbve a,ce�tifi'cate of consent to self Insure,
or,a certificate of Warker'd Cb;pensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.)
Policy No. Compo etACOUNTY 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 j y 1 liZW
partment. (PRINT OR TYPE ONLY) ADDRESS `J
SPP LOCALITY
Da A lican NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS
COMPENSATION INSURANCE S
ABSORPTION UNIT,BTU ASSESSOR
(This section need not be completed If the work Involved by the MAP BOOK PAGE PARCEL
permit Is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU r/ goo
APPROVALS DATE INSP OR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL Ir
provisions or this permit shall be deemed revoked. FURNACE: FAU_G_BAVITY / �� VAL D TION
LICENSED CONTRACTORS DECLARATION FLOOR BTU (O
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect.
License Numb e W-1 74 /-L� Lic.Class� � � s--o
Contractor Date c'" 3b—9, a ID ELC
❑ I am exempt under sec. Plan check fee C
ACCT A a
B.BP.C.for this reason PERMIT ISSUING FEE$ C2-1 Q 3303 139.30
IC-
Date: TOTAL FEE 'Q 1 ITEMS u
Signature PLAN CHECK APPLICANT TOTAL 139. 30 u,
OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law NAME
ode) ADDRESS CHECK 139.60
for
e following reason(Section 7031.5, Business and Professions 01110.
CCHANGE .40
F1
I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL.NO. nnnn n n
structure is not intended or offered for sale(Section 7044, COOD-0001 11/30/9`
Business and Professions Code). OWNER 3518 1 PM 5 02
❑ 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).
CONSTRUCTION LENDING AGENCY OSTATE
q-
I
TEL.NO O
hereby affirm that there is a construction lending agency fortheperformance of the work for which this permit Is issued(Sec.3097,Civ.C.).Lender's NamTEL.NO. J��'CCS
Lender's Address / LIC. /
I certify that I have read this application and state that the above l� 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 f p tion p j poses. SEE REVERSE FOR EXPLANATORY LANGUAGE
'SMATUREMF APPLICANT OR AGENT DATE