HomeMy Public PortalAbout6229 RENO AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 200048 DPW 9/89 APPLICATION FOR PERMIT LIME GREEN,
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I hereby affirm that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.) I
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 insp c Ion FOR APPLICANT TO FILL IN BUILDING
departm nt (PRINT OR TYPE ONLY) ADDRESS ZzOf
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Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITYi i-�
CER IFICATE OF EXEMPTION 1407M WORKERS' NEAREST
CROSS T.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
(This section need not be completed If the work Involved by the ASSESSOR
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permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person In any manner so as to BOILER.BTU
become subject to the Workers'Compensation Laws.
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APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: F
LICENSED CONTRACTORS DECLARATION FLOOR BTU .3 VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect.•
License Number OY-42WLic.Class
Contractor l (�V C
0 I am exempt under Sec. Plan.check fee 8
BAP.C.for this reason PERMIT ISSUING FEE$ '� f^.-.,' s C
Dat _.
TOTAL FEE G
Signature - u
OWN ILDER DECLA TIO PLAN CHECK APPLICANT i t
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I herebyaffirm that I m exem t from the Contractor's License Law -� �' , 47,,B r r' 1
P NAME 1 !f i I ��, �t� _ �.
for the following reason(Section 7031.5, Business and Professions
Code): ADDRESS Cil' 1K
F1 1, as owner of the property, or my employees with wages _
as their sole compensation, will do the work and the CITY TEL.NO. 1_: (^�
structure is not intended or offered for sale(Section 7044,
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Business and Professions Code). OWNER qtv
I, as owner of the property, am exclusively contracting ;;il:„: ;, • .�
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with licensed contractors to construct the project (Sec- ADDRESSPL +
tion 7044, Business and Professions Code). t.
CONSTRUCTION LENDING AGENCY CITY -KN CEL.NO
I hereby affirm that there is a construction lending agency for i
the performance of the work for which this permit Is issued CONTRACTOR Q
(Sec.3097,Civ.C.). j
ADDRESS Rd/
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 upo the above-mentioned
property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF T E