HomeMy Public PortalAbout6019 PRIMROSE AVE_Mechanical__ -WORKER'S COMPENSATION DECLARATION 2sA� PW 9189 . APPLICATION FOR PERMITGREEN
I hereby affirm that I have a certificate of consent to self insure, U 1�� Eor a certificate of Worker's Compensation Insurance,or a certified HEATING-VENT,ILATING-AIR CONDITIONINGFFFF���� LLL V 111��� �7
copy thereof(Sec.3800 Lab.C.) 7u(
Policy No. `eUbcfCompany—5-1-mm rkwp — COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certifleq copy is hereby furnished. '
Do Certified copy is tiled with the county building inspection FOR APPLICANT TO FILL IN BUILDING
ADDRESS &01q /�)Ft),56 +��,
department. ./�. (PRINT OR TYPE ONLY)
Date 3.v Applican*r�V`+ r v y NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY Y /� (�}
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST L
CROSS ST.
COMPENSATION INSURANCE
ABSORPTION UNIT,BTU ASSESSOR
(This section need not be completed if the work involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars'($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. .PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, Ishall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws. ` r f / ��D/
AWAV �� COMPRESSOR,BTU �•! APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH oe
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the.Labor Code,you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNAC • FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR ��000 BTU �o/d VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect. v
-P- 410 =' +
License Number tic.Class A(''(`I°g
c.�I�iIJ>�C{��A,�' z � :�s��l,� � ,- - 1��.a ti•�a�'.
Contractor N Date .�✓ + 0
❑ Plan check fee I� '� U
am.exempt undei Seq. TOTAL 1 1 1 o 45 O
B.BP.C.for this reason- PERMIT ISSUING FEE$
Date:. Hf�. �#.1.45.+v
TOTAL FEE CHANGE .00 a
Signature PLAN CHECK APPLICANT ff
OWNER-BUILDER DECLARATION Z
'I hereby affirm that I am exempt from the Contractor's License Law NAME , 011900-10-113-11011 9"5-
for the following reason(Section 7031.5, Business and Professions -7 h# " � ''
Code):
e): • ADDRESS 9!0 1 Air 10 a 39
I, as owner of the property, or my employees with wages'
as their sole compensation, will do the work and the CITY TEL.NO.
structure.is not-intended or offered for sale(Section 7044,
Business and Professions Code). OWNER e / D LR AIM
❑ 1, as owner of the property, am exclusively contracting MAIL r
with licensed contractors to construct the project (Sec- ADDRESS 0/9 /e�i�•pcf �
tion 7044,Business and Professions Code). CITY is /1 TEL.NO.
CONSTRUCTION LENDING AGENCY 1i
I
hereby affirm that there is a construction lending agency for CONTRACTOR G P& ,
the erformance of the work for which this ermit Is issued
(Sec.3097,Civ.C.). ZIP
• ADDRESS , $ .,�/�
Lender's Name r _
CITY TEL.NO.
Lender's Address STATE LIC.
I certify that I have read this application and state that the above LICENSE NO. CLASS
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 fc , spectio rpo es. ,I_3 Gf� SEE REVERSE FOR EXPLANATORY LANGUAGE
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SIGNATU 29F
APPLICANT OR AGENr DATE