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HomeMy Public PortalAbout6008 ROWLAND AVE_Mechanical__ WORKER'S COMPENSATION of consent to 76A348DPW9/89 APPLICATION FOR PERMIT LIME GREEN C I herKbY affirm/It1et I have a certificate of consent to self insure, 76A8f34 , or a oertlficate of.Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING copy thereof(Sec.3800 Lab.C.) Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. E] Certified copy is hereby furnished. ❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUILDING department. (PRINT OR TYPE ONLY) ADDRESS Q Q 8 Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST 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($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to BOILER,BTU become subject to the Workers'Compensation Laws. ; J0Op -S �Gu-SLG COMPRESSOR,BTU �'� .. Dat Applicant �1� S VENTILATION SYSTEM APPROVALS r DATE INSP IGNATURE NOTIC T APPLICANT: If, after making fhIs Certificate of ROUGH Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code, you must forthwith comply with such I FINAL ..3- provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY LICENSED CONTRACTORS DECLARATION FLOOR BTU 00 O 3 S VALIDATION I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED_ UNIT (commencing with Section 7000)of Division 3 of the Business and HEATER: WALL Professions Code,and my license is in full force and effect. License Number fl�©7,2 Lic.Class V �3 / /-�• - o Contracto �1'�-/�� //')-Date ❑ Plan check fee C. I am exempt under Sec. D B.&P.C.for this reason PERMIT ISSUING FEE$ cf C Date: TOTAL FEE 01,1C Signatu fJ. PLAN CHECK APPLICANT OWNER-BUILDER DECLARATION o G I hereby affirm that I am exempt from the Contractor's License Law NAME , 8 for the following reason (Section 7031.5, Business and Professions ° h Code): `` ACCT $ ADDRESS ■ I, as owner of the property, or my employees with wages �� j�1 °t{ as their sole compensation, will do the work and the CITY TEL.NO. structure is not Intended or offered for sale (Section 7044, 1 ITEMS Business and Professions Code). OWNER -p ❑ I, as owner of the property, am exclusively contracting MAIL ` TOTAL -0 34S.36 with licensed contractors to construct the project (Sec- ADDRESS/ V ��rL .f36e3 7 tion 7044,Business and Professions Code). _ J CHECK l CONSTRUCTION LENDING AGENCY CITY f �L TEL.NO.� _0 9 • CHANGE .00 I hereby affirm that there is a construction lending agency for CONTRACTOR ✓ , the performance of the work for which this permit Is issued -e _ �� 4 / (Sec.3097,Civ.C.). !�q ADDRESS/6 V OOQC-0001 12! 4/9 Lender's Name �'✓ _ CITY a. TEL.No. ��� 6880 1 AM 10:57 Lender's Address / I certify that I have read this application and state that the above LICENSE NO. CLCASS 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 for insp ction purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATURE OF APPLICANT Oft AGENT DATE