HomeMy Public PortalAbout5760 PRIMROSE AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR P E RM I T
` I hereby affirm that I have a certificatr:,of consent to self , � �°
,. insur®, or a certificate of Workers' Egmpensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
T or a certified copy thereof (Sec. 3800, Lab.1C.)1 1h, 76A364C,
20-0046 DPW 9/88
Policy No. Company - "
❑6 Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
'�❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING h `�
tion department. ADDRESS
(PRINT OR TYPE ONLY)
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST. 10,117
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. POC sv
the permit is for one hundred dollars (;100) or less.) rN, , J
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM �' 0 1`/-
permit is issued, I shall not employ any person in any manner I I
so as to become subject to the Workers'Compensation Laws. I BOILER, BTU APPROVALS DATE I CT R'S SIGNATURE
Date Applicant COMPRESSOR, BTU onn )AROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER 4A66A
withcomp with such provisions or this permit shall be deem-
ed revoked. I FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
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.
CL
License Number Lic. Class 0 0 , O
Contractor Date
❑ I am exempt under Sec. O
Plan check fee u,
B.BP.C. for this reason pyo a-
PERMIT ISSUING FEE $ V
Date: _
TOTAL FEE
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License ,
Law for the following reason (Section 7031.5, Business and NAME ;01� rr� /
Profe ns Code): `
ADDRESS
9J I, as owner of the property, or my employees with �� i -114,-e
-
wages as their sole compensation,will do the work and I ■T
the structure is not intended or offered for sale(Section CITY 4 , ,, TEL. NO. ,e—/ 3-010-1
� L r
7044, Business and Professions Code). OWNER 3.01, i L � 59.
I, as owner of the property, am exclusively contracting > I a rI`
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS -fit TAI 55?
o 00
CONSTRUCTION LENDING AGENCY CITY TEL. NO.
I hereby affirm that there is a construction lending agency for CHECK _irr_.
■I!!]
the performance of the work for which this permit is issued CONTRACTOR , r•
(Sec. 3097, Civ. C.). ICHANCI a Cl 0;
ADDRESS
Lender's Name
Lender's Address CITY TEL. NO.
I certifythat I have read this application and state that the STATE LIC. 1 fit tt n.8Ll._
PP
above information is correct. I agree to comply with all County LICENSE NO. CLASS
ordinances and State laws relating to building construction,
and hereb I^thonze representativ s of this County to enter
upon th •beve-mentioned rd for inspection pur A�oses.
.
SEE REVERSE FOR EXPLANATORY LANGUAGE
S gnature of Applicant or Agent Date