HomeMy Public PortalAbout6142 RENO AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 6 84CP'"9f89 APPLICATION FOR PERMIT URE G
�E�i heresyaffilmthat I have'a certificate of dDnserit t(tself insure, LJ
or a 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. n
❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDINGss �I�L ►C.P-w
department. (PRINT OR TYPE ONLY)
Date ApplicantLOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE / 4•
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST n
COMPENSATION INSURANCE CROSS ST. je
ABSORPTION UNIT,BTU ASSESSOR y p G
(This section need not be completed If the work involved by the MAP BOOK �I �O PAGEM �
� PARCELo t
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit �p
Is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws. / ��'"-o Q
COMPRESSOR,BTU
APPROVALS DATE I PECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL 1A A 11171
provisions or this permit shall be deemed revoked. FURNACE: FAUAff ITY
LICENSED CONTRACTORS DECLARATION / FLOOR BTU lv ATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED-UNIT-
(commencing
USPENDED UNIT(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect. ( D 114.10
License Number Lic.Class ,
1 ITEMS
a
Contractor Date �a TOTAL 114 o AL O.'
C
❑ I am exempt under Sec. ��
Ix
B.&P.C.for this reason PERMIT ISSUING FEE$ 2 CHECK 114°10 H
Date: TOTAL FEE Q CHANGE . C
Signature OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT ;1 U,
I hereby affirm that I am exempt from the Contractor's License Law NAME 1111p.
17000-0001 9� 5/95�
for the following reason (Section 7031.5, Business and Professions
1:1 ADDRESS I L e6„� X14 1 Ali E� �
I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and theCITY .t TEL.NOR
structure is not intended or offered for sale (Section 7044, a
Business and Professions Code). OWNER
1, as owner of the property, am exclusively contracting
MAIL
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
CITY TEL.NO.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for CONTRACTOR
the performance of the work for which this permit Is Issued
(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
9 al l
,
NA RE OF AP ANT OR AGENT DATE