HomeMy Public PortalAbout6523 OAK AVE_Mechanical__ (2) r % WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89 LIME GREEN
76A364C APPLICATION-FOR PERMIT
I hereby affirm that I have a certificate of consent to self insure; I
or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thei'aof(Sec:,3800 Lab.C.)
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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 G S 3 IJ• OA b`
department. (PRINT OR TYPE ONLY) ADDRESS
Date Applicant LOCALITY l Q" L i;! T
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. L r).(D I s
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
(This section need not be completed if the work Involved by the ASSESSOR y
MAP BOOK PAGE C)(I- PARCEL 0
permit Is for one hundred dollars($100)or less.) AIR HANDLING UNIT.CFM
DISTRICT NO. PROCESSED SV
I certify that in the performance of the work for which this permit
is issued, 1 shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH &
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL 7-t^ -
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY �� VALIDATION
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATERSUSPENDED UNIT
:
(commencing with Section 7000)of Division 3 of the Business and WALL
Professions Code,and my license Is in full force and effect.
License Number Lic.Class
a
Contractor Date L
El am exempt under Sec. Plan Check fee
cc
B.&P.C.for this reason PERMIT ISSUING FEE$ FC
-
Date: TOTAL FEE C
Signature a
PLAN CHECK APPLICANT U.
OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law NAME
for the following reason (Section 7031.5, Business and Professions
code): ADDRESS
I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL.NO. �"
structure is not intended or offered for sale(Section 7044, h_s i -� !
Business and Professions Code). OWNER
jT"-�'�(`
E] 1. as owner of the property, am exclusively contracting MAIL s t �
with licensed contractors to construct the project (Sec- ADDRESS 'Ik5o
tion 7044, Business and Professions Code).
HL 500
CONSTRUCTION LENDING AGENCY CITY TEL.NO. H E
_Z
I hereby affirm that there is a construction lending agency for CONTRACTOR
I performance of the work for which this permit s Issued t lAINUt
(Sec.3097,Civ.C.).
ADDRESS
Lender's Name _
CITY TEL.NO. ;.j 12 101-0 l (i
nti=
Lender's Address
certify that I have read this application and state that the above LICENSE NO. CLLASS i X. = All
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
proper r Inspection purp es. ` SEE REVERSE FOR EXPLANATORY LANGUAGE
SIG URE F APPLICANT OR AGENT DATE