HomeMy Public PortalAbout5441 RYLAND AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION
%11 hereby offtrmthvt I have a certificate of consent to self APPLOCATION FOR PERMIT
ifis*ure, or a certificate of Worker., Compensation Insurance,
or a r rtifled copy thereof(Sec. 38W, Lob. C.) 76A364C VENTILATING - AIR CONDITIONING
Policy No. Company 20-0046 DPW 9/88
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the county building inspec-
tion department. FOR APPLICANT TO FILL IN FBUILDING
(PRINT OR TYPE ONLY) ADDRESS Te
Date Applicant LOCALITY
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST
CROSS ST.
(This section need not be completed if the work involved by — ABSORPTION UNIT, BTU—
the permit is for one hundred dollars($100)or less.) DISTRICT NO. PR BY
I certify that in the performance of the work for which this — AIR HANDLING UNIT, CFM
permit is issued, I shall not employ any person in any manner
so as to b am subject to the Wp4,ers'Compensation S. BOILER, BTU
o
APPROVALS DATE INSPECTOR` IG11TUR1
ROUGH
Date,60�Toj*PPLI U 0 1,Applicant> d COMPRESSOR, BTU— ,®"),Q— M 1,(_1
NOTICB0 PPLI NT: It, aft making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER f vAb'RAT-1
with comply with such provisions or this permit shall be deem-
ed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR _BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED—UNIT—
(commencing with Section 7000)of Division 3 of the Business WALL
and Professions Code,and my license is in ful I force and effect.
License Number
Lic. Class iL
0
Contractor Date U
09
0 1 am exempt under Sec. 0
B.&P.C. for this reason Plan check fee M
PERMIT ISSUING FEE $ ACCTAA 9L
Dole: -1— W
Signature Zia 5V 44.&
TOTAL FEE 3307 F 1
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I T E NES
I hereby affirm that I am exempt from the Contractor's License
Low for the following reason (Section 7031.5, Business and 1AME1ZjTIe4*eV. TOTAL 44-.50
Q
Professions Code): % PM I LA 4E'
1, as owner of the property, or my employees with ADDRESS ALQI�l 44.50
wages as their sole compensation,will do the work and .011
the structure is not intended or offered for sole(Section CITY TEL.NO.P_
7044, Business and Professions Code).
1, as owner of the property, am exclusively contracting OWNER _R0k%%.w
with licensed contractors to construct the project (Sec- 8/31/809
tion 7044, Business and Professions Code). rDDLRESS 5437 1 All 11 as 437
CONSTRUCTION LENDING AGENCY
I hereby affirm that there Is a construction lending agency for CITY TEL. NO. 44%.
the performance of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.). ZM,
S,,qS1
Lender's Name ADDRESS _ _Z,4LA bo 40,E
CITY YC-4&PL., - TEL. NO. LJ L�S t4W
Lender's Address r (-Xv
I certify that I have read this application and state thatthe STATE LIC.
LICENSE NO.
above information Is correct.I agree to comply with all County CLASS
ordinances and State laws relating to building construction,
and hereby authorize representatives of this Country to enter
re r a 'a
p S
0
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ntionped peri in peit n poses.Aut e obove-me
4t R /_ g SEE REVERSE FOR EXPLANATORY LANGUAGE
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Applicant
li nt or Agent