HomeMy Public PortalAbout5446 PERSIMMON AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT
1 nj herelAffirm that I �oyg •a,certificate of consent to self
''isure, r a certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
Za certified copy thereof (Sec. 3800, Lab.C.) 76A364C
20-0046 DPW 9/88
Policy No. Company
Certified copy is hereby furnished.
F-11COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING [—� 6
tion department. ADDRESS l7 8—'k, 6t
(PRINT OR TYPE ONLY)
Date Applicant— LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST yy��
COMPENSATION INSURANCE CROSS ST. ,PJC( -7L$
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. / PROCESSED BY
the permit is for one hundred dollars(;100)or less.) �` D �(
I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM ((()))
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. BOILER, BTU APPROVALS 'eil).A7 I I SPECTOR'S SI TORE
Date! Applicant COMPRESSOR, BTU D ROUGH
NOTICE TO APPLICANT: If, after making this Certi cote of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER V LIDATION
withcomp with such provisions or this permit shall be deem-
ed revoked. FURNACE: FAU /ITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU 10100
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED—UNIT
(commencing
USPENDED UNIT(commencing with Section 7000)of Division 3 of the Business WALL.
and Professions Code,and my license is in full force and effect.
d
License Number�`3�55 Lic. Class �' O
2 7—
Contracto to � ,
❑ 1 am exempt under 9-9
Sec. V
Plan check fee u,
B.&P.C. for this reason PERMIT ISSUING FEE $ U Z) a.
Date: 7 31
Tf Sv
Signature TOTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT VACCT°a
I hereby affirm that I am exempt from the Contractor's LicensePoo. .,;, +4 CZ
Law for the following reason (Section 7031.5, Business and NAME 3-31-17til°`JI
Professions Code): 1 ITEMS
❑ I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work dnd CIT, TEL. NO. TOTAL 61-50
the structure is not intended or offered for sale(Section
7044, Business and Professions Code). Alt
//- / CHECK 61.5-1 ,
OWNER 6'v `l L
❑ I, as owner of the property, am exclusively contracting. MAIL fu/m �/� CHANGE
with licensed contractors to construct the project (Sec- ADDRESS% q_0'f7 10f-�1� /d-^ !�t-
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY / � / 6'7 TEL. NO.
I hereby affirm that there is a construction lending agency for ' { f 2./
the performance of the work for which this permit is issued CONTRACTOR1 AN I
(Sec. 3097, Civ. C.). 2019 Gu°
ADDRESS ?J 7 I'V /N Y'
Lender's Name
CITY /MDv$ �- TEL. NO.96a'/+f/7L_
Lender's Address i
ATE LIC
I certify that I have read this application and state that the LICENSE NO. �3O �J Ca CLASS
above 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-me tioned prop rty for in ection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
4- -y* ?O
ignature of Applicant or Agent Date