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Home My Public Portal About4913 RYLAND AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 76"64CPW9leg APPLICATION FOR PERMIT LICE GREEN; I hereby affirm that I have a certificate of consent to self insure, �t or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING `IILJI� copy thereof('Sec.3800 Lab.C.) Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV. Certified copy is hereby furnished. ❑ Certified copy is filed with the count building BUILDING ` department. y ng inspection FOR APPLICANT TO IN ADDRESS l3 LAW) J� P Date ApplicantLOCALITY NO. TYPE OF APPLIANCE OR EQUIPMENT FEE V CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST . ^o ,r_ -e COMPENSATION INSURANCE CROSS S R /��[[ff LV �w rQvz 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($100)or less.) AIR HANDLING UNIT,CFM 'VLDISTRICT NO. PROCESS�psv I certify that in the performance of the work for which this permit I/ j is issued, I shall not employ any person in any manner so as to BOILER,BTU .d become subject to the Workers'Compensation Laws. COMPRESSOR,BTU 4 3 190 23 Z! • APPROVALS DATE INSPECTOR'S SIGNATURE Date Applicant VENTILATION SYSTEM NOTICE TO APPLICANT: If, after making this Certificate of ROUGH Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code,you must forthwith comply with such FINAL Z provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVnY 2 LICENSED CONTRACTORS DECLARATION FLOOR BTU I= VALIDATION �3 I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT (commencing with Section 7000)of Division 3 of the Business and HEATER: WALL Professions Code,and my license is in full force and effect. License Number Lic.Class �� 3�� 3 V3 Contractor Date -.-ice C F-1 Plan check fee -:`,. ,— a I am exempt under Sec. ;"; _ 1�� 1 219 Q -- �, B.&P.C.for this reason PERMIT ISSUING FEE$ -2,117� +„I-I�:_:: ,! �o;^ C Date: TOTAL FEE ©r _•�"r; +�'� �i.l.. a Signature U. OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I hereby affirm that I am exempt from the Contractor's License Law NAME for the followingreason Section 7031.5, Business and Professions '04— Vrr Aq f{U O'erF! :'�. Code): ADDRESS '+J -Z I, as owner of the property, or my employees with wages as their sole compensation, will do the work and the CITY A.l TEL.NO. Z Ep/ ql structure is not intended or offered for sale (Section 7044, c� Business and Professions Code). OWNER S � ARO J ❑ I, as owner of the property, am exclusively contracting MAIL with licensed contractors to construct the project (Sec- ADDRESS tion 7044,Business and Professions Code). CITY TEL.NO. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for CONTRACTOR , the performance of the work for which this permit is Issued . (Sec.3097,Civ.C.). ADDRESS Lender's Name CITY TEL.NO. Lender's Address 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 a&SI.awsting to building construction,and hereby authorize rr upon the above-mentioned pa ti urposes. ��! SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATURE APPLIC NT OR AGENT DATE