HomeMy Public PortalAbout6263 PRIMROSE AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0046 DPW PW 9/89 APPLICATION FOR PERMIT
1 hereby aff� that I have a certificate of consent to self Insure,
or a,certificatg of Worker's Compens on Insurance, or a certified HEATING-VENTILATING-AIR COD
copy copy th�r�o(($�.3$ b.C.)
Policy N . 1—�7 SLI ompany COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnishedan
BUILDING
Certifie copy is filed with the cDsp coon FOR APPLICANT TO FILL IN ADDRESS �j
de t. (PRINT OR TYPE ONLY)
Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS
COMPENSATION INSURANCE OR
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, I shall not employ any person In any manner so as to BOILER.BTU
become subject to the Workers'Compensation Laws. Ott
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
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: Fku ]fl VALIDATION
LICENSED CONTRACTORS DECLARATION FLOOR BT `
1 hereby affirm that I am licensed un :der 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.
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'/J 1'I vt•t a8 ,
License Number v Lic.Class7f',C '
4.10 C
Contractor Date i OTAL 17 m 5 C
❑ I am exempt under Sec. Plan Check fee = Q
CHECK 79.A5 C
BAP.C.for this reason PERMIT ISSUING FEE "!� r ,fl l Jr-
CH
Date: TOTAL FEE 9. a�� LL
d
Signature U
PLAN CHECK APPLICANT
OWNER-BUILDER DECLARATION 030131-1011313141,1.41''j .t a
I hereby affirm that I am exempt from the Contractor's License Law NAME , r . t° -P''I
for the following reason (Section 7031.5, Business and Professions
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,
Business and Professions Code). OWNS ,rn
❑ 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 KSTATE
TELV� C
Ihereby affirm that there is a construction lending agency for
the performance of the work for which this permit Is issued(Sec.3097,Civ.C.).
Lender's NameO.
Lender's AddressI certify that I he ad this application and state that the above S
information isc rect. I agree to comply with all County ordinances
and State law rel Ping ho building construction,and hereby authorize
represent ti s of th' County to enter upon the above-mentioned
property If ur oses. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APPL TOR AGE T DATE