HomeMy Public PortalAbout5602 PERSIMMON AVE_Mechanical__ WC'KER'SCOMPENSATION DECLARATION Z00046DPW 9/89
78A364C L I MAI
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I hereby pAV n I have a certificate of consent to self insure, APPLICATION FOR PERMIT
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or a cefdicate of Worker's Compensation Insurance,or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.)
Policy No.r 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 ins p tion FOR APPLICANT TO FILL IN BDDRE S UILDING __Z;0,;7
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department.�r (PRINT OR TYPE ONLY)
Date 2 !� Applica LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EX ION FROM KERS' NEAREST
CROSS
COMPENSATION INSURANCE
ABSORPTION UNIT,BTU ASSESSOR
(This section noed not be completed If the work Involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO PROCESSED BY
I certify that in the performance of the work for which this permit
Is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws. ,6l //
COMPRESSOR,BTU �✓ a^i0• (O d D
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL 3
provisions or this permit shall be deemed revoked. / FURNACE: GRAVITY /
LICENSED CONTRACTORS DECLARATION ( FLOOR BTU v o.,w i V LIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect.
License Number Lic.Class ��L ® _
Contract�r/�/I�/T S}'3alate a
Plan check fee
❑ I am exempt under Sec. a
B.&P.C.for this reason PERMIT ISSUING FEE$ '� d C
Date: TOTAL FEE G �
Signature ACCT°v Cr
PLAN CHECK APPLICANT
OWNER-BUILDER DECLARATION 3303 139.30 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 1 ITEMS
Code): 39'_
_
❑ ADDRESS
I, as owner of the property, or my employees with wages TOTAL I��_e+�T6
as their sole compensation, will do the work and the CITY TEL.NO. S.ftECir 1,37 JQ
structure is not intended or offered for sale(Section 7044, CH °
Business and Professions Code). OWNER�� CHANGE °QQ
r_1 1, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044,CONSTRUCTION LENDING AGENCY CITY /Lp ('[ IL 6 TEL.N 6 .. 7 -'3/28�O/96
QQQQ-Q701
I hereby affirm that there is a construction lending agency for CONTRACTOR �/® S�/ fiC� 5586 1 FH 6�1
I performance of the work for which this permit s Issued so
(Sec.3097,Civ.C.).
ADDRESS AV
Lender's Name dr
CITY /,�f !qLNO.
Lender's Address STATE v— y�, LIC. /✓
I certify that I have read this application and state that the above I LICENSE NO. G- CLASS
information is correct. I agree to comply with all County ordinances
and State laws relating to building c struction,and hereby authorize
re sentatives of this Cou t nter upon the above-mentioned
SKURE
erty fo p on es. SEE REVERSE FOR EXPLANATORY LANGUAGE
O APPL C T AGENT DATE