HomeMy Public PortalAbout4929 PERSIMMON AVE_Mechanical__ (2) � WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9/89 LIME G
76A364C APPLICATION FOR PERMIT
I hereby,'affirm that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified 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.
Certified copy Is hereby furnished.
❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN PDDR UILDING SS ■�C�76r"�
department. (PRINT OR TYPE ONLY) ,C
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE �-
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST CROSS / QLZ4A
ABSORPTION UNIT,BTU
COMPENSATION INSURANCE OR�Q 1 #o
��/
(This section need not be completed if the work Involved by the MAP BOOK PAGE ea;Z51 PARCEL6.2– 7
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,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 BOILER,BTU
become subject to the Workers'Compensation Laws. G
COMPRESSOR,BTU
APPROVALS DATE INSPEC '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 @VIS /��D VALIDATION
LICENSED CONTRACTORS DECLARATION FLOOR BTU (J
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect. I
[ r
License Number LIC.Class • 0A 0
® a
Contractor Date C
EJI am exempt under Sec. Plan Check fee
Q
BAP.C.for this reason PERMIT ISSUING FEE C
Date: TOTAL FEE C
Signature Q
PLAN CHECK APPLICANT U.
OWNER-BUILDER DECLARATION
G
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 j?GRGG—MI V l� A L•T�T
I, as owner of the property, or my employees with wages 3307��� 118.35
as their sole compensation, will do the work and the CITY TEL.NO. �Jn7+.•.
structure is not intended or offered for sale(Section 7044, i iTEMEE
Business and Professions Code). OWNER _
❑ I, as owner of the property, am exclusively contracting MAIL TOS I AL �I.I_E o 35
with licensed contractors to construct the project (Sec- ADDRESS HECK
tion 7044, Business and Professions Code). Lua
CONSTRUCTION LENDING AGENCY CITY TEL.NO. CHANGE
IherppCONTRACTOR
eby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued o
(Sec.3097,Civ.C.). �{ii 4/>>
ADDRESS 13131311-1331.;1 4/16/9'
Lender's Name CITY TEL.NO. 7 235 Z At t 4 n�-�
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 for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APPLICANT OR AGENT DATE