HomeMy Public PortalAbout5759 ROWLAND AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I have a c%tificate of consent to self
insure, or a certificate of Worker's•Compensatiorf lnSurancb, HEAPING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec. 3800, Lab. C.) a 76A364C i
20-0046 DPN/9/88
Policy No. Company 1.
Certified 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 �1
tion department. I (PRINT OR TYPE ONLY) ADDRESS ,5 r T Cj g o w 1 A Iv
Date Applicant LOCALITY C � O /-7eD
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST rr
COMPENSATION INSURANCE CROSS ST.
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PR ED BY
the permit Is for one hundred dollars ($100)or less.)
I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM E)g
permit is issued, I shall not employ any person in any manner I
so as to become subject to the Workers'Compensation Laws. IBOILER, BTU APPROVALS DATE INSPECTO SIGNATURE
Date Applicant COMPRESSOR, BTU 1400® (J/� ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL /11 h
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER V�
with comply with such provisions or this permit shall be deem-
ed revoked. / CE. FAU GRAVITY jl
LICENSED CONTRACTORS DECLARATION FLOOR BTU go,a �f
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 my license is in full force and effect.
License Number Lic. Class V U
Contractor Date W
❑ I am exempt under Sec. O
Plan check fee u,
B.&P.C. for this reason CLPERMIT ISSUING FEE $
Date: y
TOTAL FEE
Signature
OWNER-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): _
RCW TO
I, as owner of the property, or my employees with ADDRESS ACCT.e
wages as their sole compensation,will do the work and CI TEL. NO. 3071 LYthe structure is not intended or offered for sale(Section CO — o
7044, Business and Professions Code). OWNER 1 T I EWS
I, as owner of the property, am exclusively contracting u
with licensed contractors to construct the project (Sec- AIL TOTAL 55� 0113tion 7044, Business and Professions Code). t -,L� e
CONSTRUCTION LENDING AGENCY CITY TEL. NO. (:i'ECK '55.130
1 hereby affirm that there is a construction lending agency for CHANGSE .GCI
the performance of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.).
Lender's Name ADDRESS •!313131]-1,01]x, if v/70
Lender's Address CITY TEL. NO. 939.3 I AM 09:3
I certifythat I have read this application and state that the STATE LIC.
PP LICENSE NO. CLASS
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction, I
and hereby authorize representatives of this County to enter
upon the abov -mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
ig ture of Applic t or Agent Date