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HomeMy Public PortalAbout5532 PERSIMMON AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 4f3DPW 9les APPLICATION FOR PERMIT LIME GREEN. 7gA3 I hereby affirm that I have a certificate of consent to self insure, 7sA364C or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING copy thereofP- r F L,'-j4) 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 BUILDING ADDRESS J-333 Z dep Qment. (PRINT OR TYPE ONLY) Date 2 / Applicant C" S�I������KV LOCALITY T e NO. TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. COMPENSATION INSURANCE ABSORPTION UNIT,BTU SESSOR (This section need not be completed if the work Involved by the MAP BOOK ���� PAG E,&9 PARCELe/ permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY I certify that in the performance of the work for which this permit 5O is issued, I shall not employ any person in any manner so as to BOILER,BTU— become TU become subject to the Workers'Compensation Laws. COMPRESSOR,BTU �Ov 0 APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT: If, after making this Certificate of ROUGH Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code,you must forthwith comply with such FINAL P provisions or this permit shall be deemed revoked. FURNACE: FAU TY _ LICENSED CONTRACTORS DECLARATION FLOOR BTU 7 �C� VALIDATI®N I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT (commencing with Section 7000)of Division 3 of the Business and HEATER: WALL Professions Code,and my license is in full force and effect. � License Number 6 7 �21— Lic.Class L � p �Qesz. D dcc /"lGCy,e...► CA L � � ACCT. C Contractor Date ❑ I am exempt under Sec. Plan check fee 3C{ j a a B.&P.C.for this reason PERMIT ISSUING FEE$,46— 1 ITEMS F Date: TOTAL FEE TOT/AL 114 . 45 u Signature PLAN CHECK APPLICANT CHECK 1 i4°45 U OWNER-BUILDER DECLARATION u I hereby affirm that I am exempt from the Contractor's License Law NAME ✓ C y/4 AJ(eA (_ e ' CHANGE °12I G for the following reason(Section 7031.5, Business and Professions r� Code): ADDRESS 1)2 S- C, fA,,f-rA c c A/z n, V ❑ I, as owner of the property, or my employees with wages 0000-01101 2/ 5/93 as their sole compensation, will do the work and the CITY Ap-ea TEL.NO. ��� 57fG� 77ug structure is not intended or offered for sale(Section 7044, 8.059 1 ANION Business and Professions Code). OWNER i3© g ❑ 1, as owner of the property, am exclusively contracting MAIL with licensed contractors to construct the project (Sec- ADDRESS 3 Z 10F/'z% //-7"1' -" /311� tion 7044,Business and Professions Cade). CONSTRUCTION LENDING AGENCY CITY T M L g C/T TEL.NO. I hereby affirm that there is a construction lending agency for , the performance of the work for which this permit Is issued CONTRACTOR �1 ��elyli ^/(p A L ee- (Sec.3097,Civ.C.). ADDRESS 12- S-- r rr, f Lender's Name CITY 14 o[ C 14#?e A TEL.NO. y Lender's Address STATELIC. Z I certify that I have read this application and state that the above LICENSE NO. 3 7 7 CLASS C- information is correct. I agree to comply with all County ordinances and State laws relating to building construction,and hereby authorize representatAIs jo this County to enter upon the above-mentioned propert=kTE_NT rposes. SEE REVERSE FOR EXPLANATORY LANGUAGE O S SIGNATOR AT