HomeMy Public PortalAbout6126 OAK AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION zo-o048DPW 9/89 APPLICATION FOR PERMIT LIME GREEN.
I hereby affirm that I have a certificate of consent to self insure, 76A964C
or a certificate'of Worker's Compensation Insurance,or a certified
[ EATING-VENTILATING-AIR CONDITIONING
copy thereof.(Sec.3800 Lab.C.)
Policy No. Company 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 /
department. (PRINT OR TYPE ONLY)
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS.' NEARESTCROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT T /
(This section need not be completed if the work Involved by the (/ MAP BOOK PAASSESSGE PARCEL
permit is for one hundred dollars($100)or less.) HANDLING UN CFM
DISTRICT NO, PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to I BOILER,BTU-
become
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become subject to the Workers'.Compensation.Laws. / ��d t/l.L-rte a�tJ
COMPRESSOR,BTU O
' • APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant 'VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation R TIVE D
provisions of the Labor Code,you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect.
License Number Lic.Class �. -ACCT.F
Po
o. 3303 11€x,25 a
Contractor Date 1 ITEMS
1 am exempt under Sec. Plan check fee t'
❑ TOTAL 110 .85 a
BAP.C.for this reason PERMIT ISSUING FEE$. 4 C
CHECK': 110.V•. f;
Date: TOTAL FEE CHANGE .130 a
Signature PLAN CHECK APPLICANT U
OWNER-BUILDER DECLARATION 2
1 hereby affirm that I am exempt from the Contractor's License Law NAME , 0L100-0001 ?l 6/93
for the following reason(Section 7031.5, Business and Professions
'• Code): ADDRESS, 0581 1 AM 7:52 '
❑ I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY 11 TEL..NO.
Structure is not Intended or offered for sale(Section 7044,
p� Business and Professions Code). WNER F I
�l 1, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS. Are.
tion 7044,Business and Professions Code). a
TEL.NO.
CONSTRUCTION LENDING AGENCY CIT'P/�� s
I hereby affirm that there Is a construction lending agency for CONTRA OR ,
the performance of the work for which this permit is issued
(Sec.3097,Civ.C.). •
ADDRESS' '
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. 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
propAly for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
r
SIGNATURE OF AP LICANT OR AGENT DATE i