HomeMy Public PortalAbout6334 PRIMROSE AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 20o04f3DPW 9/s9 p��L�����®N ®� ���ySA'� LIME
GREEN
76A364C /L� RAV!
I "reby affiIL 0
rm that I have a certificate of consent to self insure, �•
or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENfILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.)
Policy No. Company COUNTY 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 BDDRE 3 �3
department. (PRINT OR TYPE ONLY)
Date Applicant LOCALITY r 9
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE �r
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST.
COMPENSATION INSURANCE 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($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
Is Issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such / FINAL L�
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY en0 VALIDATION
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect.
License Number LIC.Class
RCCTA >
Contractor Date 3303 84.50 C
❑ I am exempt under Bec. Plan check fee 1 ITEMS C
D
B.BP.C.for this reason PERMIT ISSUING FEE$ a TOTAL 84.50 H
Date: TOTAL FEE if a CHECK 84.50 t7fY u
Signature PLAN CHECK APPLICANT CHANGE a CO co
OWNER-BUILDER DECLARATION 6
1 hereby affirm that I am exempt from the Contractor's License Law NAME
for the following reason(Section 7031.5, Business and Professions ® OW0-0001 10l 4/9.5
Code): ADDRESS LIfS+� �Cj t
❑ I, as owner of the property, or my employees with wages 1 AM11�37
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). 1, dWNER
❑ 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 TEL.NO.
^ C
I hereby affirm that there is a construction lending agency for CONTRACTOR
the performance of the work for which this permit Is issued �fjryz7 �
(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 inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATUREfP APPLICAk7 O /�ENi DATE