HomeMy Public PortalAbout5034 RIO HONDO AVE_Mechanical__ .r) 'WORKER'S COMPENSATION DECLARATION O64CPWf/89 APPLICATION Ya PPLICATION F®RVERMIT LIME GREEN,
I Oereby affirm that I have a certificate of consent to self Insure,
or a certificate of Work1}r's•C,ompensation 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.
❑ Certified copy is filed with the county'building inspection FOR APPLICANT TO FILL IN BUILDADDRESG INr
department. (PRINT OR TYPE ONLY) S �y n/� t!P
Date Applicant. LOCALITY
NO. TYPE. APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION,FROM WORKERS' NEAREST
CROSS ST.
COMPENSATION INSURANCEABSORPTION UNIT,BTU
(This section need not be.completed if the.work Involved by the ASSESSOR
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MAP BOOK PAGE RCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY
I certify that in the.performance of the work'for which this permit �1
is issued, I shall not employ any person in any manner'so as to I BOILER,BTU �✓j Al
become subject to the Workers'Compensation Laws. /UU
COMPRESSOR BTU �`
APPROVALS DATE INSPECTOR' TORE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making is tertificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER.-
provisions of the,Labor Code,you must forthwith comply,with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU WAVITY i )VALIDATION
LICENSED CONTF)ACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business arid HEATER: WALL V/VR��
Professions Code,'anii my license-is in full foice and effect. -
License Number Lic.Class ;
Contractor Date
r_1I em exempt under sec. Plan check fee
B.&P.C.for this reasonPERMIT ISSUING FEE$ 7j
_ I
Date: TOTAL FEE
Signature
PLAN CHECK APPLICANT
OWNER-BUILDER DECLARATION '
I hereby affirm that I am exempt from the Contractor's License Law NAMEJ b ,� ® 7 _
for the following reason(Section 7031.5, Business and Professions I r'
Code):
ADDRESS •� (^R-^�,;j_jR'
❑ I, as owner of the property, or my employees with wages
as their sole'compensation, will do the work and the CITY r TEL.NO. Z�6" % .i?: +' iy
structure.is not intended or offered for sale(Section 7044,
Business and Professions Code). OWNER
❑ I, as owner of the property, am exclusively contracting MAILi L f a
with licensed contractors to construct the project (Sec- ADDRESSe0 }
tion 7044,.Business and Professions Code). ''���I'
) CITYr TEL.NO. ..v
CONSTRUCTION LENDING AGENCY s. 17 (i�
I hereby affirm that there is a construction lending agency for CONTRACTOR
the performance of-the work for which this permit Is Issued. ;3_I"i^ a =�
(Seo.3097,Civ.C.). i^ r f i- yt2 ADDRESS tU ,•y r
i•E+LEf AL LO#�
I
Lender's Name CITY TEL.NO. ;i 1{lWG
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 [ i 1.!..
and State laws.relating to-building construction,and hereby authorize : 1? I�--i j ,j y r•�'• ?
representatives of this County to enter upon the above-mentioned 4854
i�.'.i s•�:
props ty for insp ti rposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
GNA E ft PL OR AGENT DATE