HomeMy Public PortalAbout5040 RIO HONDO AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
6r a certified copy thereof (Sec. 3800, Lab. C.) 76A364C
ft �� �+�6 ((1 20-0046 DPW 9/88
Policy No.b Company YIi IV►J
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the cou •ty uild 'ing spec- FOR APPLICANT TO FILL IN BUILDING p, (1,•� �.
tion de artment. ADDRESS 1`� tJDo
�f� (PRINT OR TYPE ONLY)
Date �jq Applicant LOCALITY G
,� NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FRIJM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST. O�
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT ISO. PROCESSED BY
the permit is for one hundred dollars($100)or less.) `7.
1 certify that in the performance of the work for which this AIR HANDLING UNIT,CFM J
permit is issued, I shall not employ any person in any manner BOILER, BTU
so as to become subject to the Workers'Compensation Laws. APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant COMPRESSOR, BTU 600 ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER �A IDATION
withcomp with such provisions or this permit shall be deem-
ed revoked. FLOOR CE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION v
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 WALL
and Professions Code,and m license is in full force'd effect. ! --e�S
CL
License Number �l Lic. Class ,Z_011 O
U
e
Contractor ' Date �-Z V o
❑ I ext pt under Sec ' U
Plan check fee y
B.&P.C. for this reasonCL
7 1J Q Z
PERMIT ISSUING FEE $
Date:
Signature TOTAL FEE
WNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License ,
Law for the following reason (Section 7031.5, Business and NAME
Professions Code):
❑ I, as owner of the property, or my employees with ADDRESS n
v'
wages as their sole compensation,will do the work and CIN OWNER
TEL. NO. ACCT.'T'-'
the structure is not intended or offered for sale(Section �y
7044, Business and Professions Code). 307 44.50
❑ 1, as owner of the property, am exclusively contracting 1 ITEMS
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS TOTAL 44.50
CONSTRUCTION LENDING AGENCY �
CITY TEL. NO.
I hereby affirm that there is a construction lending agency for CHECK 44.5[I
the performance of the work for which this permit is issued CONTRACTOR , CHANGE oGO
(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name
Lender's Address CITY TEL. NO. CIODO-0001 7/24/89
1 certify that I have read this application and state that the STATE NO. LIC.CLA4642 1 AI' :14
above 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 th a ve-menti ed property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
9' 'q
Signatufof Applicant or Age Date