HomeMy Public PortalAbout6017 PRIMROSE AVE_Mechanical__ WORKER'S,COMPENSATION DECLARATION 20.0046 DPW 9/69 +• ,
1 hereby affirm that I have a certificate Of consent to self Insure,. 7BM64C APPLICATION FOR PERMIT U 1GREEN
or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.)
Policy No.p7q Company <Tk17COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
F1Certifiec(,copy is hereby furnished.
Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN ADDRESS
department. �j] -,e n /� .7� (PRINT OR TYPE ONLY) v�
Date 41 3�5 Applicant A i y��r L(C� /�R- LOCALITY
NO. TYPE OF APPLIANCE OR EOUIPMENT FEE
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT BTU
(This section need not be.completed if the work Involved by the' MAP BOOK PAGE PARCEL
permit Is for one hundred dollars($700)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is Issued, I shall not employ any person in any manner so as to' BOILER,BTU
become subject to the Workers'Compensation Laws.
% ( COMPRESSOR,BTU SL�noo
/� bre 'APPROVALS DATE 'INSPECTOR'S SIGNATURE
Date/`�3 Applicant '• /'J rhe VENTILATION SYSTEM
NOTICE TO.APPLICANT: If., aft making Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE' FAU GRAVITY 0 VALIDATION
LICENSED CONTRACTORS DECLARATION FLOOR 50®d BTU (!�
I.•hereby affirm that-I'am licensed under provisions of Chapter 9 HEATERSUSPENDED UNIT
:
(commencing with Section 7000)of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect.
License Number Lic.Class G K "
S'
0.
Contractors�Z, GDate U'"3 f J1
F1 c:I am exempt under SePlan Check fel
BAP.C.for this reason PERMIT ISSUING FEE$ �j �j� = � °45 C
Date: TOTAL FEE �� Al
� - TE `' a
Signature TOTAL AL 11 1 m X45 V
PLAN CHECK APPLICANT �
OWNER-BUILDER DECLARATION ri f
45
I hereby affirm that I am exempt from the Contractor's License Law NAME ,Ht��. I° ,
for the following reason(Section 7031.5, Business and Professions , CHANGE I�j
Code): ADDRESS °
❑ 3 1
I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL.NOM— LI01 f j ,c
Business and Professions Code). OWNER
structure is not intended or offered for sale (Section 7044, 1
a c�7�'9 1 ��11t�::-+
•❑ R S1fi�� :jg
I, as owner,of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS' (00 1-7 P,041 (j V- A''-.
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TEL.NO.
I hereby affirm that there is a construction lending agency for CONTRACTORL ,
he performance of the work for which this permit Is Issued "C—
I N
(Sec.3097,Civ.C.).
ADDRESS S f t�mp�pr
Lender's Name /
CITY •Q k(` 0-9174 EL.NO. `33449676
Lender's Address STATE LIC. tt� �1
I certify that I have read this application and state that the above LICENSE NO. !p d 3 CLASS L'' 9L 0
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-mentioned
property finspection purposes . SEE REVERSE FOR EXPLANATORY LANGUAGE
I W e46--
SIGNATUty APPLICANT OR DATE