HomeMy Public PortalAbout5749 ROWLAND AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT
' I herby affirm that I have a certificate of consent to self
insure, or a certificate of Work&rs' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a cer6fit d copy thereof(Sec. 3800, Lqb. C.) 76A364C
'1 20-0046 DPW 9/88
Poll Vo Company
ertified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. ADDRESS S7
(PRINT OR TYPE ONLY)
Date A licanf LOCALITY
Applicant— NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS Sr. �fQ,P,�/.1,,5!AJ
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. p ESSED BY
the permit is for one hundred dollars(;100)or less.) 0e og
jLI-0 I
Icertify that in the performance of the work for which this AIR HANDLING UNIT, CFM
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 ROUGH 'ala �—_e 71-,kAAS--
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers' U f
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALI ATIO
with comply with such provisions or this permit shall be deem-
ed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED ✓ UNIT— In o
(commencing with Section 7000)of Division 3 of the Business WALL. �J
and Professions Code,and my license is in full force and effect. Ito
D tJ }
CL0
License Number Lic. Class V
/ � ,
Contractor Date
❑ 1 am exempt under Sec. O
Plan check fee v
W
B.&P.C. for this reason d
PERMIT ISSUING FEE $
Z
Date:
Signature TOTAL FEE 5 3307 49.7
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 1 ITEMS
I hereby affirm that I am exempt from the Contractor's License TOTAL 49.75
Law for the following reason (Section 7031.5, Business and NAME � ��1� CIeO
Professions Code): CHECK 49 a75
ADDRESS
® I, as owner of the property, or my employees with � ���,�� ed�
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section CITY��/7c �L y TEL. NO�J✓,5'-/B,J�
7044, Business and Professions Code).
❑ OWNER V^11�I, as owner of the property, am exclusively contracting � 0000-0001 9/18/89
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS 5756 1 AM y;^?
CONSTRUCTION LENDING AGENCY CITY TEL. NO.
I hereby affirm that there is a construction lending agency for Poo.the performance of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name
CITY TEL. NO.
Lender's Address
ATE LIC.
I certify that I have read this application and state that the LICENSE NO. CLASS
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
up the above-mention�f d property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date