HomeMy Public PortalAbout5402 PARMERTON AVE_Mechanical__ WORKER SCOMPENSATION DECLARATION 1110 DM 9/89 _ ' LIME GREEN
1 hereby elllrm that I have a certificate of consent to sell insure
�4C APPLICATION FOR PERMIT
or a Fhereof(S of worker a Compensation Insurance or a certilieA' - t 'HEATING -VENTILATING -AIR CONDITIONING
copy thereof(Sec 3800 Lab C) '
Policy No Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY,DIV xtf
❑ Certified copy is hereby furnished r ,
r BUILDING
Cenihed copy is hied vnih the conn bui Qg in ciwn FOR APPLICANT TO FILL IN ADDRESS Z
department r' ' (PRINT OR TYPE ONLY _ 1
Dalen z;67_ A Applicant, NO TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
_CERTIFICATE OF EXEMPTION FROM WORKE NEAAE5i
CROSS 5
P COMPENSATION INSURANCE ` ABSORPTION UNIT BTU r `
(This iectlon need not be completed If the work Involved by the . ASSESSOR ,
permit le for one hundred dollars($100)or leuAIR HANDLING UNIT CFM
) MAP BOOK r PAGE PARCEL
�Er ey
I certify that in the performance of the work for which this permit 2 s
ie issued I shall not employ any person in any manner so as to BOILER BTU'
become subject to the Workers Compensation Laws ) c ¢ r t
! COMPRESSOR BTU c-D - • . -
Date Applicant' VENTILATION SYSTEM ' 'oPflO'"'� DATE r wsFscraasenannr+E +
NOTICE TO APPLICANT .If eller making this Certificate of I ROUGH �(�. '
Exemption you should become subject to the'Wurkers Compensation T -
EVAI'ORATIVE COOLER `,b 1
provisions of the Labors Code you must forthwith comply with such FINAL, /u U _
provisions or this permit shall be deemed revoked ' 1 FURNACE ^ FAU=G
LICENSED CONTRACTORS DECLARATION', / FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of ChapteF B SUSPENDED—UNIT—
Professions
USPENDED UNIT_
(commencing with Section 7000) of Division 3 of the Business and HEATER
Professions Cade and my license is iri Pull force and effect \\
-1 1
License Numberkv
,c Class-Zf7 pZ
r ,T " a
Camra&l1 '�rC6Ata 2 O
❑ ,t 1 am exempt under Sec - - Plen`Gheck fee - , ' Y 4 0
B 8P C for this reason - PERMIT ISSUING FEE $ �� O'D s , ' , ` ••+
r
D e >hy> TOTAL FEE Qp W
Signature , ^ , 'd
" OWNER UIL D ION PLAN CHECK APPLICANT rr, _ , fA
Z
I hereby affirm that I am exempt fro a Contractor a License Law NAME
for the following reason (Section 7031 5 Busmess and Professions
Code)y" ' .,, ADDRESS _` ', ACCT.:
F1
I as owner of the property or my employees with wages
as their sale compensation will do the.w'ork and the CITY i r TEL NOn L ee07
structure is not intended or offered for sale (Section 7044 •' a y 1 ITEM; n
• Business and Professions Code)'-,' ' S OWNER I '�/NN
❑ I as owner of the properly am exclusively contracting I ITh1L ` cc . bo
MAIL
with licensed contractors to construct the project (Sec ADDRESS C 'Svr1.�l�1
non 7044 Business and Professions Code) HECK' J_
' ' CITY t TEL N ��,x
CONSTRUCTION LENDING AGENCY l � CFtl'I '. ,IIQ
I hereby affirm that there is a construction lending agency for Poo u
CONTRACTOR -i1 -
the performance of the work for which th'a permit is issuedAma ) Q ,
(Sac 3097 Civ C)
Lender sLm
Nae } ADDRESS 'r rx-,fdi_GOQ1 • 12/11/90 ,
C TEL NO Z�,r(.� + + - - L444V4V1 1 PML:1G
Lenders Address STATELIC
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 Sta laws relating to building construction and hereby authorize
represe tativM
ty ta'en r upon the above mentioned 't
'prOP far Ipoae9 ' M
SEE REVERSE FOR EXPLANATORY LANGUAGE