HomeMy Public PortalAbout5744 RIO HONDO AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 7OA348DPW9/89 APPLICATION FOR PERMIT LAME GREEN
78A364C
I he . aff0m that I_4ave a certificate of consent to self Insure,
or certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.)
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cy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
BUILDING
❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN ADDRESS 14
department. (PRINT OR TYPE ONLY)
Date ApplicantLOCALITY IH � I
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS ST.
COMPENSATION INSURANCE W 0-(�,M0\V-1
ABSORPTION UNIT,BTU ASSESSOR �/ / 85W7-004
(This section need not be completed if the work Involved by the MAP BOOK ! 2- PAGE�/jj PARCEL 0 1
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit f
is Issued, I shall not employ any person in any manner so as to BOILER,BTU �y
become subject to the Workers'Compensation Laws. to
COMPRESSOR,BTU ��'���
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL .Z
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that 1 am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect. -
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License Number Lic.Class
ACCT.s
id
3303 54.75 a
Contractor Date C
F11 am exempt under Sec. Plan Chef fee 1 ITEMS C
cc
BAP.C.for this reason PERMIT ISSUING FEE$ TOTAL 54 -75 C
Date: TOTAL FEE 'ZeCHECK 54.75
SignatureA{aGE ° 0 LL
PLAN CHECK APPLICANTfr.
OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law NAME
for the following reason (Section 7031.5, Business and Professions 0000-0001 7/23/96
Code): ADDRESS 761$ 1 Ptd 5°' 1.
❑ 1, as owner of the property, or my employees with wages U°
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 10i-Nf�Itl� 'TA
MV .. S�UNI, as owner of the property, am exclusively contracting MAIL n
with licensed contractors to construct the project (Sec- ADDRESS �� � r,I0 H QN\-)Q
tion 7044,Business and Professions Code). d
CONSTRUCTION LENDING AGENCY CITY —CL H e LL GI-c� TEL.NO.Q Ig
I hereby affirm that there Is a construction lending agency for CONTRACTOR 101.
the performance of the work for which this permit Is issued L' if�
(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 ate laws relating to building construction,and hereby authorize
repr entatives of this County to enter upon the above-mentioned
pro rty for inspection purposes. 99 SEE REVERSE FOR EXPLANATORY LANGUAGE
'SIGNATURE OF AP7ANT OR AGENT DATE