HomeMy Public PortalAbout5755 OAK AVE_Mechanical__ WORKER ISavCOMPENSATION
ate of consent to 7OA364 DPW 9189 APPLICATION FOR PERM T LURE GREEN
I hereby affirm than I have a c(stificate of consent to self Insure 7f1A984C
or a certificate of Vilorker a Compensation Insurance or a certified
copy thereof W1 C) HEATING VENTILATING AIR CONDITIONING
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Policy No Companyh_ C'� COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
❑ Certified copy is hereby furnished �p� off-f-4-
❑ Certified copy is filed with the county building Inspection FOR APPLICANT TO FILL IN BUILDING O w
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dep tment D (PRINT OR TYPE ONLY) ADDRESS 575-6- -
Date 2 Applicant NO TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY -� ��
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST Z�
COMPENSATION INSURANCE CROSS ST
ABSORPTION UNIT BTU ASSESSOR
(This section need not be completed the work Involved by the MAP BOOK PAGE"-41PARCEL/�
permit is for one hundred dollars($1000)or leas) AIR HANDLING UNIT CFM DISTRICT NO Prem BY
certify that in the performance of the work for which this permit
is Issued 1 shall not employ any person in any manner so as to BOILER BTU G
become subject to the Workers Compensation Laws v "„�DO
COMPRESSOR BTU K 1 4,0
APPROVALS DATE INSW a SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT If after making this Certificate of ROUGH
Exemption you should become subject to the Workers Compensation EVAPORATIVE COOLER
provisions of the Labor Code you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked FURNACE FAU GRAVITY
LICENSED CONTRACTORS DECLARATION I FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and HEATER WALL
Professions Code andmylicense is in full force and effect M /) lit !eA
License Number �i6 9 Lic Class v � ((!! "7� e l V
0111".
Contractor�oka'et Date ` o a
El am exempt under Sac Platt check Tee ` o- I� ACCT.: V
B&P C for this reason PERMIT ISSUING FEE$ 3M 80.50 O
1 ITEMS
Signature Dare TOTAL FEE lo -40 TOTAL 80.50 a
OWNER BUILDER DECLARATION PLAN CHECK APPLICANT OEM 8O.W U)
I hereby affirm that I am exempt from the Contractors License Law NAME , bID'0711R. W Z
for the following reason(Section 7031 5 Business and Professions
Code) ADDRESS
❑ I as owner of the property or employees with wages 11
as their sole compensation will do the work and the CITY TEL NO
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)
CONSTRUCTION LENDING AGENCY CITY TEL NO
I hereby affirm that there is a construction lending aggency for ,
I he performance of the work for which this permit is issued CONTRACTOR
(Sec 3097 Civ C)
ADDRESSO tS� L
Lender a Name
CITY TEL NO )8
Lender s Address
I certify that I have read this application and state that the above LICENSE NO LIC
e—Z-0
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 rty for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
4 Z3
SIGNATUREFOF APPUCANT OR AGENT DATE