HomeMy Public PortalAbout9076 RANCHO REAL RD_Mechanical_1991-11-08 :. NlORK6R'S COMPENSATION DECLARATION 20-0048 DPW 9/89 J IICATION FOR PERMIT LIME GREEN
I hereby afTirm that I have a certificate of consent to self Insure, 7BA364C APPL
ora certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-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.
❑ BUILDING r A ,, ' _
Certified copy is filed with the county building inspection FOR APPLICANT OR TYPE TO IN ADDRESS q�� 10 Nmvl�'�
department. i �
Date Applicant I LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' I q NEAREST
O �'9 CROSS
COMPENSATION INSURANCE
ABSORPTION UNIT,BTU ! O ASSESSOR
(This section need not be completed if the work Involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
Is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws. Q
I COMPRESSOR,BTU
1 n- I ^� R'S SIGNATURE
Date V Y � � Applicant �� VENTILATION SYSTEM APPROVALS DATE INSPECTOR'S
NOTICE TO APPLICANT: if, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL 111-2i-4
e
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect.
License Number S`7� 4 LIC.Class C
Contractor Date ( t C
❑ I am exempt under Sec. Plan check fee C
a
BAP.C.for this reason I PERMIT ISSUING FEE$ F
Date: TOTAL FEE go
G
Signature `
PLAN CHECK APPLICANT
OWNER-BUILDER DECLARATION s U
NLA-I e•e C
1 hereby affirm that I am exempt from the Contractor's License Law NAME ',;;, —
for the following reason (Section 7031.5, Business and Professions 73" 01.3
0
Code): ADDRESS
ElT-(1=�i:
. }
I, as owner of the property, or my employee's with wages i s L-1 I;.
as their sole compensation, will do the work and the CITY TEL.NO. j U.i AL 73 -00
structure is not intended or offered for sale(Section 7044, , �p � 3'
Business and Professions Code). OWNER r� C. EC 1:1,01_)
❑ I, as owner of the property, am exclusively contracting : IGr 1
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th vL ,13 131
with licensed contractors to construct the project (Sec- ADDRESS at
tion 7044, Business and Professions Code). NO
CONSTRUCTION LENDING AGENCY CITY TEL. r fl; z i, ,�,
I hereby affirm that there is a construction lending agency for -. ► 0111 i_I•-:,Cl'!1 y EU 6;;y
hereby
of the work for which this permit Is issued CONTRACTOR 3� ` (�,�
(Sec.3097,Civ.C.). J ,`7=- Ail fl w;11i
ADDRESS �-� Z 1 v 11� Iry f Ar
Lender's Name
CITY oz. TEL.NO. 7D1�� fg
Lender's Address STATE LIC.
I certify that I have read this application and state that the above I 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
LA L Q41
SIGNATURE OF APPLICANT OR AGENT DATE