HomeMy Public PortalAbout10200 NADINE ST_Mechanical__ WORKER SCOMPENSTONDECLARATION DPW 910 APPLICATION FOR PERMIT LIME GREEN
I hereby affirm that 1 have certlfics�of consent to seltalnaure 78A884C
or a certificate of Workers Compensation Insurance Ota certified .HEATING-VENTILATING AIR CONDITIONING
copy thereof(Sec 3800 Lab C)
Policy No Compiny COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
❑ Certified copy Is hereby furnished
❑ Cecopy Is filed with the county building Inspection FOR APPLICANT TO FILL IN BUILDING �Jaj 4a
(PRINT OR TYPE ONLY) ASR 0 2
Date ApplicantLOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CLRTFICATE OF EXEMPTION FROM WORKERS
NEAREST
STpig
COMPENSATION INSURANCE ABSORPTION UNITBTU
(This section need not be completed H the work Involved by the MAPBOOKPAGE PARCEL D/y
permR Is for one hundred dollars($100)or less) AIR HANDLING UNITCFM DlemlOT NO PROCESSED BY
I certify that In the performance of the work for which this permit p00
Is Issued I shall not employ any person In any manner so as to BOILER BTU p J
become subject to the Workers Compensation Laws O
COMPRESSOR BTU O9 COD
APPROVALS DATE 111WOR8"NA
Date APpllcant VENTILATION SYSTEM
NOTICE!TO APPLICANT If after making this a Icate 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 VALIDATION
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 HFATE WALL
Professions Code and my license is in full force and effect
iq
license Number Lic Class yO.s ACCT.a
}
Contractor Date =.+Q 164.7
❑ 1 am exempt under Sec Plan check fee 1 ITEMS
Q
B aP C for this reason PERMIT ISSUING FEES O TI ITAL 164-900
Date TOTAL FEE CHECK 1b4.9n w
Signature �
OWNER BUILDER DECLARATION PLAN CHECK APPLK:ANT u CHAMGE •00 Z-
1 hereby affirm that I am exempt from the Contractor a License Law NAME
for the following reason(Section 7031 5 Business and Professions VtRJd_ 1 aJ iy7J�f334
Code) ADDRESS 11D�� l� 0=
Q�as owner of the property or my employees with wages 4076 1 AM 9:N
as their sole compensation will do the work and the TEL NO
structure Is not Intended or offered for sale(Section 7044
Business and Professions Code) OWNER
❑ 1 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 CITY TEL NO
I hereby affirm that there Is a construction lending agency for jQ16ovic
,
the performance of the work for which this permit la Issued CONTRACTOR
(Sec 3097 Civ C)
ADDRESS
Lender s Name
ENO :390-7z)7--)
TEL NO
Lander s Address LIC
I certify that I have read this application and state that the above CLASS
information is correct I agree to comply with all County ordinances
and State laws relating to building construction and hereby authorize
resentatives of this County to enter upon the above mentioned
I'llty r in pection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
L3
SIGNATURE OF AP O DI1TE