HomeMy Public PortalAbout9538 PENTLAND ST_Mechanical__ WORKER'S COMPENSATION DECLARATION ;�°�C pW9 89 APPLICATION FOR PERMITMXEN,
a hereby elifirnr that I have a certificate of consent to self insure, •
Gr a•ceffificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy.thereof(Sec.3800 Lab.C.) u
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 AUILDING
DDRESS C
PRINT OR TYPE ONLY) �" J
department. � �')
LOCALITY
Date Applicant
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS �
ABSORPTION UNIT,BTU ASSESSOROR
(This section need not be completed if the work involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. ROC D BV
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU �O.1
become subject to the Workers'Compensation Laws. U
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL _��
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED-UNIT-
(commencing
USPENDED UNIT(commencing with Section 7000)of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect. r
License Number Lie.Class
Contractor Date ® g C
F1Plan check fee ACCT.a
I am exempt under Sec. 0
B.&P.C.for this reason PERMIT ISSUING FEE$ p 33503 31.55
Date: TOTAL FEE �. T� ITEi -t�.
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT CHANGE ,(]02
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 2293 00011
f3d '
I, as owner of the property, or my employees with wages e
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 Code). WNER a u Z
❑ I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS IF7c
tion 7044,Business and Professions Code).
CITY '�- TEL.NO.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for CONTRACT
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
property r inspection purpose . SEE REVERSE FOR EXPLANATORY LANGUAGE
OF APP.. T O
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