HomeMy Public PortalAbout5414 PARMERTON AVE_Mechanical__ WORKER S COMPENSATION DECLARATION 2pB-pDC64 DPW gin APPLICATION FOR, ••PERMITt
I hereby affirm that I have a certificate of consent to self Insure LliNE `GREEN•
or a certihcalerof Worker a Compensation Insurance or a certified , + r HEATING - VENTILATING-AIR CONDITIONING" -
copythAeof(SbE 3800 Lab C)
Policy No 'Company COUNTY OF LOS ANGELES 'DEPT OF PUBLIC WORKS y BUILDING AND SAFETY DIV
Cemhed copy is hereby furnished I ' ' ' 1 J F
❑ Cemhed copy is flied with the county building msDsction , FOR APPLICANT TO FILL IN , BUIL 98 Y O„
department _ (PRINT OR TYPE ON�V)
Date T i ' r LOCALITY
Appl¢eni G 'Oe . y.� +t `
- , NO TYPE OF APPLIANCE OR EQUIPMENT FEE o c
NEART
CERTIFICATE OF EXEMPTION FROM WORKERS ~ CROSS T E Dai n2S '
COMPENSATION INSURANCE (, _ ABSORPTION UNIT BTUr - '
,
(This section need not be completed If the work Involved by the ASSESSOR aw-
- PARCEL
IMrmlt In for one hundred dollars($100)or less) , AIR HANDL9O UNIT-CFM MAP BOOK PAGE
egiq w vBorFaem By
certify that in the performance of the work forlwhmh this permit
rs Issued I shall not employ any person in any manner so as to ' BOILER BTU
become subject to the Workers Compensation Laws, , •..�.�
• ' _ COMPRESSOR BTU 3101
` rmrrovua W.re nsvcczon s morunt�a
Dais Applicant VENTILATK)N SYSTEM ' !WC
NOTICE TO APPLICANT If after making this Certificate of - ROUGH', 'I•' ' r
Exemption-you should become subject to the Workers Compensation EVgPORATIVE COOLER a
' provisions of the,Labor Code you must forthwith comply with such FINAL
provisions or this permit shell be deemed revoked " FURNACE FAU ITV ! r
LICENSED CONTRACTORS DECLARATION I FLOOR BTU low VALIDATION t , • '
' I hereby affirm that 1 em licensed under provisions of Chapter 9 HEATER SUSPENDED - UNIT= . P
•� (commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code and my`license is In full force and effect
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- Lwense Number l,c Class 0-S + '
L
Contractor v 1 Delo , f 5 i ,. O
❑ tPlan check fee - U
I,am exempt untler Sec ;
B 8P C for this reason PERMIT ISSUING FEES Q It
Date - TOTAL FEE W
Signature • .s d
OWNER BUILDER'DECLARATION t PLAN CHECK APPLICANT i t CD
I hereby affirm thavl am exempt from the Contractor a License LawNAME ?
for the following reason (Section,7031 5 Business and Professions -
Code) n
I as owner of the ADDRESS - ' AGC 1
property ' .T '
p p y ,or my employe with wages
as their Bole compensation will do the work and the CITY ' TEL NO • ' ' 330 + t* 13c'75
structure 191nol Intended or offered for sale-(Section 7044 r ' ^ - 1`3q EMS
'r
Business and Professions Code) F, OWNER J
❑ I as owner of the properly am exclusively contracting s •' t s r IL T IAS y r -c
with licensed contractors to construct the project (Sec ADDRESS -64 ' r Irl1 nV�' • 1135
1 s �-cr
tion 7044 Business and Professions Code) _ ' - ' ' t CHECXt 1��.T! '
CONSTRUCTION LENDING AGENCY ;r CITY-12,MTELW 144* Q/ r I_H� _ ,ul
hereby affirm that there is a construction lending agency for CONTRACTOR
the performance of the work for which this permit;Is issued y - _ y'.
IS 3097 Civ C) _ , c-' + r'd i r
r ADDRESS 4 1
Lenders Name ` UC�CI- �11 11/ �/]'� '
r
CITY TEL No 7553I AM11'11
.Lenders Address P
STATE '� •+ a LICA . - :+' ,�( -r • -, .
I certify that I have reed ihl9 application and slate that the above � LICENSE NO CLASS
inform rtlon Is correct I agree to comply with all County ordinances
and State laws relating to building constructron and hereby authorize
repress ryes of this County to enter upon the above mentioned
props r inspection purp9ses _ SEE REVERSE FOR EXPLANATORY LANGUAGE-- -
SpNA OF APPI.x;ANT0 AOE Wm
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