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HomeMy Public PortalAbout5617 SANTA ANITA AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 2D 0046 DPW 9/89 CJ APPLICATION FOR PERMIT LlME GREEN I hereby affirm that I have a certificate.of consent to self Insure, 76A864C or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING copy thereof(Sec.3800 Lab.C.) Policy No.l32DU Cam any f COUNTY OF LOS ANGELES DEPT OF PUBLIC_ WORKS BUILDING AND SAFETY DIV. ❑ Certified copy is hereby.fur ❑ Certified copy is file h the ounty building inspection FOR APPLICANT TO FILL IN BUILDING ���' Ja/yt /'�1 ru..l.�r department. (PRINT OR TYPE ONLY) LOCALITY Date Z Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTI FROM WORKERS' NEAREST COMPENSATION INSURANCE GROSS ABSORPTION UNIT,BTU ASSESSOR (This section need not be completed If the work involved by the MAP BOPARCEL {� permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM DISTRICT No. PROCESSED BY I certify that in the performance of the work for which this permit -is Issued, I shall not employ any person in any manner so as to BOILER,BTU become subject to the Workers'Compensation Laws. h COMPRESSOR BTU APPROVALS DATE INSP R'S SIGNATURE' Date Applicant VENTILATION SYSTEM NOTICE'TO APPLICANT: If, after king this Ce ificate of ROUGH1 W-114 Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER provisions of the Labor Code,you must forthwith comply with such 4 FINAL 1(0 provisions or this permit shall be deemed revoked. FURNACE: FAU R ITY LICENSED CONTRACTORS DECLARATION FLOOR —BTU-- VALIDA ION I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED—UNIT— (commencing USPENDED UNIT(commencing with Section 7000)of Division 3 of the Business and HEATER: WALL e Professions Code,and rry license is in full force and effect. • 3303 License Number. & 7 3 -Lic.Class G-2D ..C� TOTAL 404-40 � Contractor Date J C ❑ I am exempt under sec: Plan check fee CHANGE �ci{( C B.&P.C.for this reason �' PERMIT ISSUING FEE$ IV F Date: I�t i t -�7 1]1 :I/31.194 u TOTAL FEE Signature5419 AM 7.0 45 OWNER-BUILDER DECLARATION PIAN CHECK APPLICANT U G I hereby affirm that I am exempt from the Contractor's License Law NAME for the following reason'(Section 7031.5, Business and Professions Code): ADDRESS ❑ I, as owner.of the property, or my employees with wages as their sole compensation, will do the work arid the CITY TEL.NO. structure is not intended or offered for sale(Section 7044, `` �'�+ Business and Professions Code). OWNER NSI ET r � + A[S ❑ I, as owner of the property, am exclusively contracting MAIL with licensed contractors to construct the project (Sec- ADDRESS aZYi OL 209 ' tion 7044, Business and Professions Code). /� CONSTRUCTION LENDING AGENCY CIN �. i4M�Q — TEL.NO. I hereby affirm that there is a construction lending agency for CONTRACTOR SI �� the performance of the work for which this permit is issued (Sec.3097,Civ.C.). ,. ADDRESS $o?� ,_�uk'Qwr ©cqo Lender's Name CITY TEL.NO.9V?SRS 15sw Lender's Address STATE LIC. l._-'•- I certify that I have read this application and state that the above LICENSE NO. fj 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 property W.nspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE _51 G URE OF APPLICANT O�A.E DATE