HomeMy Public PortalAbout6000 OAK AVE_Mechanical__ WORKERS COMPENSATION DECLARATION APPLICATION FOR PERMIT
1 hen3by affirm that I have a certificate of consent to self
insure or a certificate of Workers Compensation Insurance �� HEATING - VENTILATING AIR CONDITIONING
oar a cern i4A copy thereof(Sec 3800 Lab C)
20-0046 DPW 9/88
Poyq No Company
Certified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the county budding inspec FOR APPLICANT TO FILL IN BUILDING g"ej `j
tion department ADDRESS 1.
(PRINT OR TYPE ONLY)
Dote Applicant LOCALITY NO TYPE OF APPLIANCE OR EQUIPMENT FEE � r4
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST
COMPENSATION INSURANCE CROSS ST
(This section need not be completed K the work involved by ABSORPTION UNIT BTU 7 iczym DISTRICT NO P D BY
the permM Is for one hundred dollars($100)or less) AIR HANDLING UNIT CFM
I certify that in the performance of the work for which this
permit is issued I shall not employ any person in any manner BOILER BTU
so as to bec me subject to the Workers Compensation�ws APPWVALS DATI INSPECTOR S Se133NATURe
Date Applicant COMPRESSOR BTU ROUGH
NOTICE '�,
T If afte making this Certificate of VENTILATION SYSTEM FINAL
Exempt n u ld become subject to the Workers
Compensate n
or,
of the Labor Code you must forth EVAPORATIVE COOLER V IDA
fICA
with compI with such provisions or this permit shall be deem
ad revoked FURNACE FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
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 WALL
and Professions Code and my license is in full force and effect ;06— _193
d
License Number Lic Claas10. O
V
Contractor Date
❑ I am exempt under Sec G
Plan check fee
B&P C for this reason N
Date PERMIT ISSUING FEE $ Z
Signature TOTAL FEE
125 OWNER BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor s License
Low for the following reason (Section 7031 5 Business and NAME
Professions Code) 8
1 as owner of the property or my employees with ADDRESS '��*
wages as their sole compensation well do the work and CITY TEL NOr
the structure is not intended or offered for sale(Section 3�7 �]
7044 Business and Professions Code) OWNER
I as owner of the property am exclusively contracting 1 ITM
with licensed contractors to construct the project (Sec MAIL
tion 7044 Business and Professions Code) ADDRESS TOTAL 39.75
CONSTRUCTION LENDING AGENCY CITY TEL NO i`EC( 39.75
1 hereby affirm that there is a construction lending agency for ,
the performance of the work for which this permit is issued CONTRACTOR .00
(Sec 3097 Civ C)
ADDRESS
Lenders Name def
CITY TEL NO D 1
�7M 10/24/89
Lenders Address STATE LLC 6374 1 AM 9:53
I certify that 1 have read this application and state that the LICENSE NO CLASS
above information is correct 1 agree to comply with all County
ordinances and State laws relating to budding construction
and hereby authorize representatives of this County to enter
upon the above mentioned property for ens ction urposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
gnature of Applicant or Agent 7t.
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