HomeMy Public PortalAbout4954 ROBINHOOD AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION zaooasDPW sfas APPLICATION FOR PERMIT LAME GREEN
78A364C
I hdreby affirm that I have a certificate of consent to self Insure, y
or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENT16ATING-AIR CONDITIONING
copy thereof SSec.1800 Lab.C.)
Policy N� 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 ouilding inspection FOR APPLICANT TO FILL IN BUILDING
department. (PRINT OR TYPE ONLY) ADDRESS
Date ApplicantLOCALITY v
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU ASSESSOR
(This section need not be completed If the work Involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that In the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws. O
I COMPRESSOR,BTU ii 49
APPROVALS GATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL 11z
provisions or this permit shall be deemed revoked. FURNACE: FAU Ib VALIDATION
LICENSED CONTRACTORS DECLARATION FLOOR BTU f
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect.
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License Numb
Lie.Class�!� f/'� ACCT a a
3303 109a0c
Contractor ate
❑ i am exempt under Sec. Plan check fee 1 ITEMS C.
BAP.C.for this reason PERMIT ISSUING FEE$ 0 TOTAL �� a �c
Date :TOTAL FEE �/o CHEC(: 10$a0
CHANGE aGo a
Signature PLAN CHECK APPLICANT U,
OWNER-BUILDER DECLARATION �
1 hereby affirm that 1 am exempt from the Contractor's License Law NAME , 0000-0001 11/15/95_
for the following reason (Section 7031.5, Business and Professions
Code): ADDRESS a 3316 1 AM 10 a S7
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
❑ 1, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TEL. '
I hereby affirm that there is a construction lending agency for ,
the performance of the work for which this permits Issued CONTRACTOR f -
(Sec.3097,Civ.C.).
ADDRESS ,
Lender's Name
CI TEL.NO 'a
Lender's Address .
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1 certify that I have read this application and state that the above LICENSE NO. CLLASS vV
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 upon the above-mentioned
property o oses. SEE REVERSE FOR EXPLANATORY LANGUAGE
r •
S RE p AP I ANT OR AGENT DATE