HomeMy Public PortalAbout5703 RIO HONDO AVE_Mechanical__ WORKER'S COMPENSATION
certificate
of consent ON 20-nG4aDPW 9/89 APPLICATION FOR PERMIT
LIME GREEN
I herey affirm,That I have a certificate of consent t� self insure, 76A364C
or a certificate of Worker's Compensatiop Insurance,or a certified 11 HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.) "0
�
cy 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 count buildingFOR APPLICANT TO FILL IN BUILDING
department. y inspection (PRINT OR TYPE ONLY) ADDRESS �� }_..•
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE �
CERTIFICATE OF EXEMPTION FROM WORKERS' NEARESTT. C a
COMPENSATION INSURANCE CROSS
ABSORPTION UNIT,BTU ASSESSOR
(This section need not be completed if the work Involved by the MAP BOOK PAGE PARCEL
permit 1s for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU ���
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTIC O"APPLICANT: If, after m ing this Certificate of ROUGH
Exemption,you should become subject to he Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL 1/L fsl�
provisions or this permit shall be deemed revoked. FURNACE: FAU AX GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU kD VALIDATIorMCT-
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
�50 111x70
(commencing with Section 7000)of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect. 1 ITEMS
�i��del �d A TOTAL 11 A 0 70
License Number Lic.Class ®��,�
��rr CHECK 111070 c
Contractor �E/'r Date 04 5 , CHANGE .00 C
I am exempt under Sec. Plan check fee 0
B.BP.C.for this reason PERMIT ISSUING FEE$ 30 0000-0001 10/ 2/95 f
te: s TOTAL FEE �� 2571 1 At110 26 u
Signature 'J O
PLAN CHECK APPLICANT (J
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License L NAME ►
for the following reason (Section 7031.5, Business and Professions
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.
structure is not intended or offered for sale (Section 7044,
Business and Professions Code). OWNER
F1 1, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS /C'3 A04-eO
tion 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY C TEL.NO.
1 hereby affirm that there is a construction lending agency for CONTRACTOR A,
the performance of the work for which this permit Is issued Ilfv
(Sec.3097,Civ.C.).
ADDRESS ✓a �.
Lender's Name
CITY AleTEL.NO.
Lender's Address STATE ��++�-�j Ids LIC. �f
I certify that I have read this application and state that the above LICENSE NO.(�/ CLASS 4
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
re entatives of ' County to enter upon the above-mentioned
ope y for in act' purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APPLICANT OR AGENT DATE