HomeMy Public PortalAbout6039 PRIMROSE AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I'hereby affirm"that I have a certificate of consent to self
insure, or a certiflcate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a.certified copy thereof'(Sec. 3800, Lab. C.) 76A364C
!A-PC- #Vl V. 10/81)
Policy No.02 gompany �LL-�9o�T r/I/ COUNTY OF LOS ANGELES - BUILDING AND SAFETY
Certified copy is hereby furnished.
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING 603
j'd //���
tion department.
o. (PRINT OR TYPE ONLY) ADDRESS �N/3
Date —Z o pplicantNO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
CERTIFICATE OF EXEMPTION FROM K NEAREST `
COMPENSATION INSURANCE CROSS ST.
(This section need not be completed if the work Involved by ABSORPTION UNIT,BTU DISTRICT NO. PROCESSED B
the permit is for one hundred dollars($100)or less.) �l( -
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM
permit is issued, I shall not employ any person in any manner
BOILER,BTU
'so as to become subject to the Workers'Compensation LOWS. APPROVALS DATE I TOR'S SIGNAT RE
Date Applicant COMPRESSOR,'BTU--19"0 d ROUGH
NOTICE TO APPLICANT: If, after making this Certificate'of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAUGRAVITY
LICENSED CONTRACTORS DECLARATION. FLOOR BTU l r�
I hereby affirm that I am licensed under provisions of Chapter 9SUSPENDED UNIT
'(commencing with Section 7000)of Division 3 of the Business HEATER WALL
and Professions Code,and my license is in full force and effect.
License Number 1O�S 6 S Lic. Class 0020 V
Contractor Date
❑ I am exempt un a ec. 9713. 1 A
Plan check fee i
B.BP.C. for this reason' # 0 0 0 0 0
Date: PERMIT ISSUING FEE$ f S—
Signature TOTAL FEE rI o - 4275
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT o o 4 2 7 5 5
I hereby affirm that I am exempt from the Contractor's License
Law for the fgllowing reason (Section 7031.5, Business and NAME .0528-87
Professions Code):
❑ I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and CITY TEL. NO.
the structure is not intended or offered for sale(Section
7044, Business and Professions Code). _OWNER �+��`' /� 7S0 ,o
r N�h i'l.
❑ 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 r LE e�Z TEL. NO.
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTO /�— t�01ID/77[)/U/I�/ /WC ,
(Sec. 3097, Civ. C.).
ADDRESS `f(f S'� 4144 2) S /gV6
Lender's Name er _
CITY .94r I?,4,6
&C—L TEL. NO(y4r22 �3
Lender's Address STATE LIC.
I certify that I have read this application and state that the LICENSE NO. „SO SS 6-r CLASS CAP
above 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
upbove-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ;
kant or Agent Date
Sig�_of�Pl