HomeMy Public PortalAbout5435 RYLAND AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION �2000aeDPwsiBs APPLICATION FOR PERMIT
7eA3�° LIME GREEN
1 h�reby affirm that i.have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR,CONDITIONING
copy thefeof(Qec.3800 Lab.C.) J u
fit, Company_ !a Tt� T�GlNGI
PolicyNo.�L���L ,Z� COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy Is hereby furnished.
Certified copy is filed with the county building Ins ction FOR APPLICANT TO FILL IN BUILDING '/
department. (PRINT OR TYPE ONLY) ADDRESS �d `�V .
Date Applicant LOCALITY a` �j /,
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE �a
CERTIFICATE OF EXEMPTI FROM WORKER NEAREST
COMPENSATION INSURANCE CROSS ST.
ABSORPTION UNIT,BTU ASSESSOR
(This section need not be completed if the work Involved by the MAP 800K PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the tor-rtrhich this permit
is issued, I shall not employ an son in any manner so as to BOILER.BTU
become subject to the Work Compensation Laws. �� �U
COMPRESSOR,BTU AI 1_?,Z bao 16714
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE T PPLICANT: If, after making this Certificate of ROUGH -��
df
Exemptic ,you Jj± An
should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisi sof the Labor Code,you must forthwith comply with such FINAL
provisions or this
LICENSED CONTRACTORS DECLARATION FLOOR C�T OBTU O GRAVITY
—
LICENSED � D VALIDATION
1 hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED—UNIT—
(commencing
USPENDED UNIT(commencing with Section 7000)of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect.
License Number ` LIC.Class -7 0 '
, 10
Contractor9f G ��" Date a / 00 C
F1Plan check fee C
I am exempt under Sec. a
B.&P.C.for this reason PERMIT ISSUING FEE$ D(, I C
' Date: TOTAL FEE Q n
Signature u
OW E -BUILDER DEC TION PLAN CHECK APPLICANT 2
I hereby affirm that I exempt from th ontractor's License Law NAME ,
for the following reason(Section 7031.5, Business and Professions -
Code): ADDRESS ttvT,z
❑ I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL.NO. L Ifl 55•13101
structure is not intended or offered for sale(Section 7044, ,,rr q T
Business and Professions Code). OWNER �,a �6r 1 I 1 h-3
I C��Y
❑ I, as owner of the property, am exclusively contracting j��A, �' ,n,
with licensed contractors to construct the project (Sec- ADDRESS r4-/v �, TOTAL � ® SLP -
tion 7044, Business and Professions Code). / CHECK 55.00
TEL.NO.
CITY -L s Z/3
CONSTRUCTION LENDING AGENCY � � t Hia��'•3C ,4 fl�
I
hereby affirm that there is a construction lending agency for CONTRACTOR ��L ,1 Jr �i ,
I performance of the work for which this permit Is issued /1 /U
(Sec.3097,Civ.C.). /I,^^ /,�
ADDRESS �b,7 % G��� �v� t(ili00-[- Ir1171/i9/90
Lender's Name sl�..t�1 CITY. 7, EL.NO. �:
/V �l2 CQ. 1 �0 45791 1 Arl10 48
Lender's Address
I certify that I have read this application and state that the above ILCENSE NO. �!a f LIC.
C
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 fo inspection pur ses. ,a SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURVAFIPLTCANT OR AGENTU TE