HomeMy Public PortalAbout6251 PRIMROSE AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 2DDD4BDPW 9/a9 APPLICATION FOR PERMIT L��E GREEN,,I
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I hereby affirm that I have a certificate of consent to self Insure,
`•,o`ro b certlficpYve o�f,,3Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
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Policy No. •- Company OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
Certified copy is filed with the county building Inspection FOR APPLICANT TO FILL IN BUILDING
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department. /� /� y- (PRINT OR TYPE ONLY)
Date �4 3 Applicant A.4 A 4 IN NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS ST. CL /
COMPENSATION INSURANCE ('moi/
ABSORPTION UNIT,BTU ASSESSOR
(This section need not be completed If the work Involved by the I MAP BOOK PAGE PARCEL
permit Is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
As issued, I shall not employ any person in any manner so as to BOILER.BTU
become subject to the Workers'Compensation Laws. llvU
COMPRESSOR,BTU V
APPROVALS DATE INSP R'8 SIGNATURE
Date - Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH i'-22 4 "
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL
provisions or this permit.shall be deemed revoked. FURNACE: FAU V I TION
LICENSED CONTRACTORS DECLARATION FLOOR BTU ((JJ `J
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED—UNIT—
(commencing
USPENDED UNIT(commencing with Section 7000)of Division 3 of the Business and HEATER: WALL Ni
Professions Code,and my license is in full force and effect.
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License Number 1 h �� Lic.Class` Z d �3
Contractor sUlo tate 6(-5 7/ -'-' - Q
❑ Plan check fee '•»-±_; L
I am exempt under Sec. -
B.&P.C.for this reason PERMIT ISSUING FEE$ "'I!€-i_. �_ r�1, = _°fis�i C
Date: TOTAL FEE ` F i-'� i.t!`';'
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Signature
PLAN CHECK APPLICANT `=i in! `. (0/
OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law NAME
for the following reason (Section 7031.5, Business and Professions , i_I j'•I:^;-j1 �s j �;;C,
Code):
ADDRESS _
❑• 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,
$usiness and Professions Code). OWNER rM
❑ I, as owner of the property, am exclusively contracting
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with licensed contractors to construct the project (Sec- ADDRESS -;I _
tion 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY CI TEL.NO;2k6_-7&J b
Ihereby affirm that there is a construction lending agency for iJ
CONTRACTOR ,
the performance of the work for which this permit Is issued N r �IU
(Sec.3097,Civ.C.).
Lender's NamADDRESS Ja I(� J -.
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CITY ZQ1U� �� TEL.NO. —fPV�/
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Lender's Address a
I certify that I have read this application and state that the above LICENSE NO. r.9 CLASS D
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
repres atives of this County to enter upon the above-mentioned
pro 6 for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
IGNATURE OF PLICANT6R.rSi ENT DATE