HomeMy Public PortalAbout5440 PERSIMMON AVE_Mechanical__ 20-01346 DPW
1N)PKER'S COMPENSATION DECLARATION 76A364C 989 APPLICATION FOR PERMIT �Ij J►1 VL4�1— aPI heraN"affirm that I have a certificate ofconsent.4o self insure,
or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.) d
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 ection FOR APPLICANT TO FILL IN BUILDING n
PRINT OR TYPE ONLY) ADDRESS d
department. ( Y) rk
LOCALITY
Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS
ABSORPTION UNIT BTU ASSESSOR
(This section need not be completed if the work involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. P ESSED BY
I certify that in the performance of the work for which this permit
is Issued, I shall not employ any person In any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU
elpAPPROVALS DATE INSPECTOWS SIGNA-
Date Applica VENTILATION SYSTEM
NOTICE O A P I ANT: If, after makin sCertificate of ROUGH
Exemption,you should become subject to the W rkers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,yomust fort ith comply with such FINAL
u
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and HEATER: WALL
Professions Code,and my license Is in full force and effect.
License Number Lic.ClassL � -
% f�D�-.LsL. C
Contractor ZZO ,,is ri F A A 7 (C-'
❑ Plan check fee
I am exempt under Sec. C
BAP.C.for this reason PERMIT ISSUING FEE$AJQ6
Date: TOTAL FEE o O
Signature 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
JL
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. ::r!(,'• t:7 0
structure is not intended or offered for sale(Section 7044, r 7Tiw`•I,
Business and Professions Code). OWNER // Is-) ` _
❑ I, as owner of the property, am exclusively contracting MAIL u r Tf
l s A; I 19 `� 0
with licensed contractors to construct the project (Sec- ADDRESS —
tion 7044, Business and Professions Code). CITY TEL.NO. / •F+i_I }, I y f p I
CONSTRUCTION LENDING AGENCY �+ ti:; �iGE o I�
Ihereby affirm that there is a construction lending agency for CONTRACTOR
the performance of the work for which this permit Is issued
(Sec.3087,Civ.C.). ADDRESS q-
41 _
Lender's Name - • -� "
CITYQO _�1 TEL.NO. � ,`{)J!s'
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 Count to enter upon the above-mentioned
pro inspects pur oses. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIG OFA 'LI O AGE DAT