HomeMy Public PortalAbout9842 VAL ST_Mechanical__ . WOFIKER'SCOMPENSATION DECLARATION 76A364ecDPW 9/99 - APPLICATION FOR PERMITLIAAE GREEN.
I hereby 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 thereof(Sec.3800 Lab.C.)
Policy NIg2 SaCompany_' COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
❑ Certified copy is filed with the countyg P ADbuilding Inspection FOR APPLICANT TO FILL.IN BUILDRESS
DING
department. (PRINT OR TYPE ONLY) v
Date ApplicantLOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST ` O
CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
(This section need not be completed if the work Involved by the ASSESSOR
permit is for one hundred dollars($100)or less.) AIR HANDLING.UNIT,CFM MAP BOOK PAGE PARCE
DISTRICT NO. PROCESSED BY
I certify,that in the performance of the work'for which this permit
Is Issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws.
/ COMPRESSOR,BTU 156Y,000' G
n Date A IICBnt r -' APPROVALS -DATE INSPECTOR'S SIGNATURE
PP• VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code;you.must•forthwith comply with such FINAL
-provisions or this permit shall be.deemed revoked. FURNACE: FAU GRAVIJY
LICENSED CONTRACTORS DECLARATION FLOOR BTU O v V 'LI ATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of.the Business and HEATER: WALL
Professions Code;and my license is in full force and effect.
License Number
LID.Class
Contractor Date ® C
❑ •1 am exempt under Sec.• iPlan check fee
'
1 .
BAP.C.for this reason PERMIT ISSUING FEE$ C
D TOTAL FEE
Signature PLAN CHECK APPLICANT , U,
OWNER-BUILDER DECLARATION . 2
P. •-r j
I hereby affirm that I am exempt from the Contractor's License Law NAM ® �•' �'
for.the following reason(Section 7031.5, Business and Professions, - 7
Code).. :.._ .*.
ADDRESS
1, as owner of'the property,oir my employees'with wages {. f•1C.
as their sole compensation, will do•the work and the CITY TEL.NO. DQnR r - - '
structure Is not intended or offered for sale Section 7044, �� -' t 4aI_ �' �'' '
Business and Professions Code). OWNERWZSAmi: .,,- �:
I, as owner of the property, am exclusively contracting '"s"� t . 47"'
with licensed contractors to construct.the project Sec- MAIL' CHANGE.
P 1 ( ADDRESS �^�iyj�G
tion 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TEL.NO.
I hereby affirm that there is a construction lending agency for ® �,-r r�-c r r - �.�•-:
the performance of the work for which this permit is Issued CONTRACTOR si_)i•irI—L;_._i= ;, ;,�:t�
(Sec.3097,Civ.C.). y + ,
ADDRESS is y(}•J y A 1
Lender's Name
CRY TEL.NO.
Lender's Address -
1 certify that I have read,this application and state that the above CENSE NO. CLLASS
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 for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE '
TUNE OF APPLICANT OR