HomeMy Public PortalAbout4945 RYLAND AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
!, hereby affirm that I have a certificate of consent to self
insure,,or a certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec. 3800, Lab. C.) 76A364C a
120-0046 20-0046 DPW 9/88
Policy'No. Company
❑ Certified copy is hereby furnished. COUNTY OF LOS ANGELES I BUILDING AND SAFETY
I _
❑ ,Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING r
tion department. ADDRESS
I (PRINT OR TYPE ONLY)
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST. J
(This section-need not be completed tf the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PR BY r
the permit is for one hundred dollars(;100)or less.) Q
I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM I G u
permit is issued, I shall not employ any person in any manner BOILER, BTU
so as to be ome su ject to the Workers'Compensation Laws_ APPROVALS DATE INSPECTOR'S SIGNATURE
7�
Applicant COMPRESSOR, BT Oct r ROUGH
NOT E TO PPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exempt'a , you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER kkilD/ATIO
with comply with'such provisions or this permit shall be deem-
ed revoked. LUORONRCE : FAU BT VITY
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED—UNIT
(commencing
USPENDED UNIT(commencing with Section 7000)of Division 3 of the Business WALL.
and Professions Code,and my license is in full force and effect.
c >-
d
License Num
;2 6 f2 Lic. ClassG —ze? � o
Contra Date
�� �_
❑ 1.I am exempt unde Sec. V
Plan check fee LU
8.8P.C. for this reason IL
ISSUING FEE $ /!0 .5--DH
Date: Z
Signature TOTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License Poo.Law for the following reason (Section 7031.5, Business and NAME
Professions Code): p
❑ I, as owner of the property, or my employees with
ADDRESS aJ
wages as their sole compensation,will do the work and ACCT.4
the structure is not intended or offered for sale(Section CITY I TEL. NO.
❑
7044, Business and ProfessionsOWNER.Code). '� 3307 4 ■ l
I,as owner of the property, am exclusively contracting 1 ITEMS,
with licensed contractors to construct the project (Sec- MAILi7
tion 7044, Business and Professions Code). ADDRESS O TOTAL 44 o 50
CONSTRUCTION LENDING AGENCY
CI TEL. NO.
I hereby off that there is a construction lending agency for _
ffCHECK 44-90
the performance of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.). , CHANGE .00
ADDRESS e)
Lender's Name r� r��y �t�L 8
TEL. NO: � 5� 010'0001 7/ / 7
Lender's Address ATEr /+ .
I certify that I have read this application and state that'the SENSE NO._,,Z3 �L CLCASS G �� 4299 - AM
above information is correct. I agree to comply with all County 1 ` �
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
upon t a ve-mentioned pert or inspecti purpo s. I
` f SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Dat , @