HomeMy Public PortalAbout9207 WEDGEWOOD ST_Mechanical__ WORKER'S COMPENSATION DECLARATION Vimi8DPW9/89 APPLICATION FOR PERMIT `IME GREEN,
I hgreby gffi�m that I have a certificate of consent to self insure, 76A984C
or a certificate of Worker's Compensation Insurance,or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thoof(Sec.3800 Lab.C.) u
Policy No. Company 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 inspection FOR APPLICANT TO FILL IN BUILDING
ADDRESS �j (�
department. (PRINT OR TYPE ONLY)
Date ApplicantLOCALITY '-7-e-m Le
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' 4DISTRICT
EAREST
NO. PROCESSED BY
COMPENSATION INSURANCE ROSS ST. (mac.✓
ABSORPTION UNIT,BTU SSESSOR 66
(This section need not be completed if the work Involved by the AP BOOK PATE-�� PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
I certify that in the performance of the work for which this permit
Is issued, I shall not employ any person in any manner so as to BOILER.BTU p
become subject to the Workers'Compensation Laws. o w+c%:p 00
COMPRESSOR,BTU O
Date Applicant APPROVALS DATE INSPECTOR'S SIGNATURE
PP VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY da VALIDATION
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATERSUSPENDED UNIT
:
(commencing with Section 7000)of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect.
License Number LIC.Class
a
Contractor Date C
❑ I am exempt under Sec. Plan Check fee B
B.&P.C.for this reason PERMIT ISSUING FEE$ ACCUT' C
37 iO3 75 L
I Date: TOTAL FEE LL
Signature ITEMS �
Cr
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT .y TOTAL
��3 � 75 3
1 hereby affirm that I am exempt from the Contractor's License Law NAME t 1 193.75
far the following reason(Section 7031.5, Business and Professions 4- J , WE€K
Cogs): I.
ADDRESS ! Z O -7 �� CHAWGE XIl
01 I, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITYTEL.NO.
structure is not intended or offered for sale (Section 7044, '� {'_ � 1� i�y-
Business and Professions Code). Q �I
OWNER V V i
❑ I, as owner of the property, am exclusively contracting MAIL 8427• 1 AM 8:49
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044,Business and Professions Code). CITY TEL.NO.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending.agency for ,
the performance of the work for which this permit s issued W IV c= U'r L '
(SecCONTRACTOR
.3097,Civ.C.).
ADDRESS
Lender's Name
CITY TEL.NO.
Lender's Address STATE LIC.
I certify that I have read this application and state that the above LICENSE NO. 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 for'nspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APPLICANT OR AGENT DATE