HomeMy Public PortalAbout5014 RYLAND AVE_Mechanical__ WdRKER'SCOMPENSATION DECLARATION 200048 DPW 9/89
APPLICATION FOR PERMIT LlME GREEN
I hereby affirnp"that I have a certi4lcate of consent to self insure, ��
or a_certiTlcate'of Worker's Compensation Insurance, or a certified I HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.) fu
Policy No. Company �ICOUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
BUILDING
❑ Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN ADDR SS�(f I 1g ymmo Ave- 7E'NFpLF e°
department. (PRINT OR TYPE ONLY)
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FI NEAREST
EE ,t n
CERTIFICATE OF EXEMPTION FROM WORKERS' C OSS ST. ;S!)f/ O Z-4 RO-M
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
(This section need not be completed if the work Involved by the ASSESSOR
MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100),or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is Issued, I shall not employ any person in any manner so as to j BOILER,BTU p
become subject to the Workers'Compensation Laws. �p
AIA10
COMPRESSOR,BTU
APPROVALS DATE IN ECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAUBTG I
LICENSED CONTRACTORS DECLARATION FLOOR U .0 VALID�ATIO 4
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and I HEATER: WALL ACC °w
a
Professions Code,and my license is in full force and effect.
_ 3303 114°10
License Number LID.Class rods 7'[! 1 ITEMS
Contractor Date
tie�i GCcG! 3 C� '
TOTAL �.� -o �.� O
❑ I am exempt under sec. Plan check fee y CASH 114.10 U
BAP.C.for this reason PERMIT ISSUING FEE$
o CHANGE .00 0
Date: I V
TOTAL FEE 0000-0001 162/ 1/95 a
Signature OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT T ` ,e ,. ,3'535 1 PM12e2a Z
I hereby affirm that I am exempt from the Contractor's License Law NAME KA S( i +VU1,1kD /sK1 4NA ►
��`ffo,,,r,,the following reason (Section 7031.5, Business and Professions ,,pp�/ yy�� /t T
\e): ESSS-0/qt-O/ ^J L•7/1Q 141,1
I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITYI'TE L� C�� TEL.NO Q�B� ���3i6
structure is not intended or offered for sale(Section 7044, O
Business and Professions Code). OWNER KATs'tJTrQ NFA w�
MAIL / 1
❑ I, as owner of the property, am exclusively contracting 1 �� ��Nk0 !s l
with licensed contractors to construct the project (Sec- ADDRESS SjqH /48D V&
tion 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TEL.NO.
I hereby affirm that there is a construction lending agency for T ,
the performance of the work for which this permit Is issued I B2e
(SecCONRACTOR
.3097,Civ.C.).
ADDRESS
Lender's Name
CITYi TEL.NO.
Lender's Address STATE LIC.
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
and State laws relating to building construction,and hereby authorize
representatives of this County to enter upon the above-mentioned
pro rtEforins ction urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
M
a1
SI RE OF APPLICANTWRIAGENT DATE