HomeMy Public PortalAbout6438 TRELAWNEY AVE_Mechanical__ WORK20-OD4
COMPENSATION DECLARATION aDPW GIN APPLICATION FOR PERMIT LIME GREEN
I hereby affirm thattI have have a certificate of consent to self insure 7BA3O
or a certificate of Worker a Compensatloh Insurance or p certified HEATING -VENTILATING -AIR CONDITIONING
copy thereof(Sec 3800 Lab C) ,
Policy No Company c ' 'COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
❑ Candied copy is hereby tummhedNG-
❑ Carolled copy is need win the toothy building inspection FOR APPLICANT TO FILL IN pip 2
department (PRINT OR TYPE ONLY)
Date Applicant LOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENTFEE
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST
COMPENSATION INSURANCECROSSST
ABSORPTION UNIT BTU
(This t Issection need noted dollars
o the work Involved by the ASSESSOR
P BOOK PAGE PARCEL
permit Is for one hundred dollen(>f 100)or Uu) AS HANDLMO UNIT CFM D,smtcr ra pRa.E�
I certify that in the performance o1 the work for which this permit l'
is issued I shell not employ any person In any manner so as to BOILER BTU S p}{
become subject to the Workers Compensation Laws v
COMPRESSOR BTU
rrnRoeua DATE 8S`Wnwe
Data 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 shell be tleemetl revoketlFURNACE FAU_ORAVT'
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter BHEATER SUSPENDED UNR_
(commencing with Section 7000) of Division 3 of the Business and WALL
Professions Code and my license is in full force and affect
L 0
License Number Lic Class
a
Canlrectar
Data O
❑ I am exempt under sec Plan check fee U
Q
B aP C for this reason PERMIT ISSUING FEE$
Date TOTAL FEE W
Signature OWNER BUILDER DECLARATION PLAN CHECK APPLICANT Z
I hereby affirm that I em exempt from the Contractor a License Law NAME ,
for the following reason (Section 7031 S Business and Professions
Code)
I as owner of the property or my employees with wages ADDRESS
El 3303 34'5L
e9 their sole compensation will do the work and the CRY TEL NO 1 ITEIT_
structure is not intended or offered for sale (Section 7044
Business and Professions Code) OWNER FOTAL 34 . 5. 0
I as owner of the property am exclusively contracting MNL i_ IY �t..- t Td)
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044 Business and Professions Code) CHANE ,at
CONSTRUCTION LENDING AGENCY CRY TEL NO
I hereby affirm that there Isa construchon'lending agency for CONTRACTOR
the performance of the work for which this permit a issuetl
(Sec 3097 civ C> CL00-17001 71 n.94
Larders Nenre ADDRESS 5975 2 FI'I 5:15
CITY TEL NO
Lender a Address STATE UC
I certify that I have read this application and state that the above LICENSE NO CUSS
MfonrolonI agree to comply with all County ordinances
an laws retabng to building construction,end hereby authorize
rase+ eves of this County to enter upon the ebov entioned '
P(
ops r ins tion purposes t SEE REVERSE FOR EXPLANATORY LANGUAGE
610NA ARE CF APRIGNr AnEM M