HomeMy Public PortalAbout6322 PRIMROSE AVE_Mechanical__ `• WORKER'S COMPENSATION DECLARATION 20-0046 DPW 9186 APPLICATION FOR PERMIT
LIME GREEN
'
I hsreby affirm that I have a certificate of consent to self Insure, 78A364C
or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy tof(Sep8U010,L�ab.C.)
p❑K�/h'cyy o.�/�T� Company � O COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
Certified copy is filed with the countybuildin inspection FOR APPLICANT TO FILL IN BUILDING
/ d art ant. g Ins p (PRINT OR TYPE ONLY) ADDRESS
Date Applicant //l LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS ST
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
SSSOR
(This section need not be completed if the work involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROLE eY
I certify that in the performance of the work for which this permit //
is issued, I shall not employ any person in any manner so as to BOILER,BTU
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become subject to the Workers'Compensation Laws.
I COMPRESSOR,BTU r//rQ'�`r
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL _
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
1 hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and
/effect. �a
License Number Lic.Clas44 CL
sy'`3�
Contractor ate
❑ I am exempt un er Sec. Plan check fee L
PERMIT ISSUING FEE$B.&P.C.for this reason
Q _ C
Date: TOTAL FEE 10L
r't'r•4 3 e 3' )J,
Signature �•�-� +�"` I'.e 0
PLAN CHECK APPLICANT l ��F:,. :'ins•- (/
OWNER-BUILDER DECLARATIONG
1 hereby affirm that I am exempt from the Contractor's License Law NAME , 1 USIS
for the following reason(Section 7031.5, Business and Professions �. �t,�-
Code): ADDRESS TOTAL -_0-2 o 0 o
❑ 1, as owner of the property, or my employees with wages r PI7r*1L 512 e f)
as their sole compensation, will do the work and the CITY TEL.NO. L
structure is not intended or offered for sale(Section 7044, CHANGE .C13
Business and Professions Code). OWNER
❑ 1, as owner of the property, am exclusively contractingi
with licensed contractors to construct the project (Sec- ADDRESS Irlt{_(-1-1-jLly .AIL 7'
41 'rT
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TEL.NO. �? %r j il�;b
I hereby affirm that there is a construction lending agency for Cc TRACTO ,
the performance of the work for which this permit Is issued
(Sec.3097,Civ.C.).
ADDRESS /
Lender's Name
CI TEL.NO. • '
Lender's Address STATE LIC. �//./�J/
I certify that I have read this application and state that the above LICENSE NO �WW CLASS ex.07J&
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
propqrty for in pection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
DATE
SIGNATURE OF APPLICANT OR AGENT