HomeMy Public PortalAbout6026 PRIMROSE AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 200048 DPW 9/89 /��D��^.A'r�®A1 ®R PERMITLIME GREEN
76A364C APPLICATION�1s1 1\I
I hereby aK rry that f have a certificate•of consent to self insure, n
or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING '�uf
copy 4hereof(Ser.3800 Lab.C.) ,
Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
❑ FOR APPLICANT TO FILL IN BUILDING
Certified copy is filed with the county building Inspection
department. (PRINT OR TYPE ONLY) ADDRESS 6
Date —Applicant LOCALITY — L
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE ABSORPTION UNIT,BTU CROSS ST.
ASSES(This section need not be completed If the work Involved by the MAP BOOK �',,j PAGE 3 PARCEO�
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU &-Xiec C7 (F O
APPROVALS DATE INSPECTOR'S SIG URE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY VALIDATI 111
LICENSED CONTRACTORS DECLARATION FLOOR Id, BTU IJ
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect. too
License Number LID.Class �r��.
a
Contractor Date ACCT.v C
❑ I am exempt under Sec. Plan check fee ix
B.&P.C.for this reason PERMIT ISSUING FEE$ D 1 ITEMS 118.30 C
c
Date: TOTAL FEE 8, 8 TOTAL 1 VL5 o 30 a
Signature U.
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT CHECK 118°303
1 hereby affirm that I am exempt from the Contractor's License Law NAME ��) ® CHANGE .00
for the following reason (Section 7031.5, Business and Professions °
Code)' ADDRESS
Iz-orI I, as owner of the property, or my employees with wages 26 p
I0000-0001 5/28/96 as their sole compensation, will do the work and the CITY TEMPLE TEL.NO. t�
structure is not intended or offered for sale(Section 7044, 6607 1 Anil°°17
Business and Professions Code). OWNER
F1 I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY O s.. TEL.NO. ! ^�
I hereby affirm that there Is a construction lending agency for CONTRACTOR
the performance of the work for which this permit Is Issued
(Sec.3097,Civ.C.).
ADDRESS
Lender's Name
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 for inspe tion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
"16
SIGNATURE.APPLICANT ORA ENT DATE