HomeMy Public PortalAbout9711 WEDGEWOOD ST_Mechanical__ WORKER'S COMPENSATION DECLARATION 46DPW 9/e9 APPLICATION FOR PERMIT [L�11MU,E GREE�J
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I hereby 9sflrlr"that I have a certificate of consent to self insure, 76M84C
or certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.) �^
Policy No. /' 2 ompany aLA� 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 ��
department. / (PRINT OR TYPE ONLY) ADDRESS
1 Alaml&fm�q
LOCALITY
Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE ^�
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' pl
COMPENSATION INSURANCE CROSS f+
ABSORPTION UNIT,BTU ASSESSOR
(This section need not be completed If the work Involved by the MAP BOOK PAGE PARCEL
permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU L7
become subject to the Workers'Compensation Laws. � C-J
es
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED-UNIT-
(commencing
USPENDED UNIT(commencing with Section 7000)of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect. J
�
License Number �( � Lic.Class
11110.
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Contracto Date ACCT o 4 U
3; c-a
F1 Plan check fee I am exempt under Sec. "SOL _ .13 n,4
�. LI:B.&P.C.for this reason
PERM ISSUING FEE$ EE 1 ITEMS EMS C
Date. f 0 TOTAL I-3 m 90 W
TOTAL FEE
Signature
CHECK 53.90 n.
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT CHANGE .00
Cr
_
I hereby affirm that I am exempt from the Contractor's License Law NAME
for the following reason(Section 7031.5, Business and Professions 001.
Cod
❑e) 1, as owner of the property, or my employees with wages ADDRESS 0000-0001 7/13195
as their sole compensation, will do the work and the CITY TEL.NO. 1314 1 AM 1:31
structure is not intended or offered for sale(Section 7044,
Business and Professions Code). OWNER Z 0 g r 2.
❑ I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY /^� TEL.NO.
I hereby affirm that there is a construction lending agency for CONTRALTO [' r- ,
the performance of the work for which this permit Is issued
(Sec.3097,Civ.C.).
ADDRESS
Lender's Name
TEL.NoW7Ll O�
CITY
Lender's Address
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 inspection, roses, SEE REVERSE FOR EXPLANATORY LANGUAGE
7//�
DAT
A RE OF APPLICANT OR AGENT I °