HomeMy Public PortalAbout5948 RENO AVE_Mechanical__ DECLARATI
WOJlxat I COMPENSATION
ate of consent to 20-D048DPW 9/89 APPLICATION FOR PERMIT LI E GREEN
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I hereliq,alfirrq)bat I hav9 a certificate of consent to self Insure,
8P a'certiflcatd of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy theraof(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 nooREss
department. (PRINT OR TYPE ONLV)
Date ApplicantNO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY'
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS 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($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY ,
1 certify that in the performance of the work for which this permit
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Is Issued, I shall not employ any per n in any manner so as BOILER,BTU
become subject to the Workers'Comp sation Law
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applic Sot VENTILATION SYSTEM
NOTICE TO APPLICANT: If, War making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL 12/
provisions dr this
LICENSED CONTRACTORS DECLARATION FLOORCE: F,AU BTU VRY a VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and WALL p�
Professions Code,and my license is in full force and effect. 6 g
//��,�������� aN ACCT°
License Number. Lic.Class.— /, 'D 3303 1S1o90
f 00. >
Contractor t"Dat l � �9-6 1 ITEMSC
❑ i am exempt under Sec. " Plan check fee_ TOTAL 151-91) C:
B.&P.C.for this reason PERMIT ISSUING FEE$ p CHECK 151°90 C
Date: TOTAL FEE CHANGE °00 u
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT U,
000a-0001. 1/23/96 2
1 hereby affirm that I am exempt from the Contractor's License Law NAME
for the following reason(Section 7031.5, Business and Professions , 4-'679 1 AN10:59
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 Zq
structure is not intended or offered for sale(Section 7044,.
Business and Professions Code). OWNER
❑ I, as owner of the property, am exclusively contracting MAIL IF
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044,Business and Professions Code). 1� ,
CONSTRUCTION LENDING AGENCY CITY t/V TEL.NO.
I hereby affirm that there is a construction lending agency for CONTRACTOR ,
I performance of the work for which this permit s issued
(Sec.3097,Civ.C.).
' ADDRESS '.
Lender's Name
CITY TEL.NO.
Lender's Address
I certify that I have read this application and state that the above I LICENSE NO. LIC.
Information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize ,
re s fives of this o my to ent upon the above-mentioned
0 or inspe"-PT0
SEE REVERSE FOR EXPLANATORY LANGUAGE
03
GNA URE OF APPLI DATE