HomeMy Public PortalAbout6059 OAK AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 7�64CPW 9189 APPLICATION FOR PERMIT L�MfV�E
I heoeby affirrrf that I have a certificate of consent to self insure,or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.)
Policy No. !2"y9 I?! Company- S►`/}T—ts- ,COUNTY 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
ADDRESS X054 N- IDA, (L
department. (PRINT OR TYPE ONLY)
Date t 2-1 l A licant �` LOCALITY Teo G 1
pp NO. TYPE OF APPLIANCE OR EQUIPMENT FEE l T
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS
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($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION I FLOOR BTU 01 VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect.
License Number -6--FIC ;'5141 Lic.Class C`L 0 1
1:. s a
Contractor ) AIC Date l t. �� =-,.Iz 1410.55 CC
E] i`( �Plan check fee
I am exempt under Sec. ; {E a
B. 1&P.C.for this reason J PERMIT ISSUING FEE$ �d r �-.5 H
I L 5 / TOTAL •5. a .B
Date: TOTAL FEE �{yg r( {i.; cc Ll
Signatures ��^'� r (/
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT t`HANGE
1 hereby affirm that I am exempt from the Contractor's License Law NAME , c
for the following reason (Section 7031.5, Business and Professions
35.
Code): ADDRESS Vii±I_ii_E^_!LI?I f �:?��i��sr .`t
❑ I, as owner of the property, or my employees with wages i ► E'i I}J°11+7
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 Cade). OWNER IVR, CSCN
F1 I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS 60-T 9
tion 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY i;-al ! TEL.NO.
I hereby affirm that there is a construction lending agency for CONTRACTOR ^-
the performance of the work for which this permit is Issued /�� r
(Sec.3097,Civ.C.).
ADDRESS (?sL1
Lender's Name CITY � TEL.NO..?
Lender's Address STATE LIC.
I certify that I have read this application and state that the above LICENSE NO. s 5 cj�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 for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APPLICANT OR AGENT OATE