HomeMy Public PortalAbout5323 WELLAND AVE_Mechanical__ e YYORKER'SCOMPENSATION DECLARATION 0-0046 DPW 9fe9 'APPLICATION FOR PERMIT L I�NE GREEN.
I hereby affirm that I have a certificate of consent to self insure,
o,a certificq(e of Worker's Compens ' n Wartified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.)JKyNCOUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
otic No. CompanCertified copy is hereby furnis ed.
FOR APPLICANT TO FILL IN ADDRESS N
Certi d copy filed with the county building Inspection ADDRESSS
Dateep rtment. (PRINT OR TYPE ONLY)
Applicant ! NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
NEAREST
CE TIFICATE OF EXEMPTION FROM WORKERS' CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
(This section need not be completed if the work Involved by the MAP SSBOOK PAGE PARCEL
permit Is for one hundred dollars($100)or less.) AIR HANDLING UNIT CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU I$-
p
become subject to the Workers'Compensation Laws. p ��t�Q�tP�e
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH Z
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 GRA
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
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. { rj O
Ca / d ry i... C L`.
License Number Lic.Class
CL
Cont Date ® qy _$I_ .._ _ C
ElI am exempt under sec. Plan check feeY7 a
B:&P.C.for this reason PERMIT ISSUING FEE$ >• = C
Date: TOTAL FEE D
Signature 4
PLAN CHECK APPLICANT
OWNER-BUILDER DECLARATION
1 herebyaffirm that I am exempt from the Contractor's License Law ® '7C;i-:= -
P NAME 1 r t i+j` f e
for the following reason(Section 7031.5, Business and Professions
Code): ADDRESS
ElI, as owner of the property, or my employees with wages
as their sole compensation, will do the work and the CITY TEL.NO.
structure is not Intended or offered for sale(Section 7044,
Business and Professions Code). OWNS
❑ 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).
CITY TEL.NO. -
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending aggency for CONTRALTO
the performance of the work for which this permit rs issued
(Sec.3097,Civ.C.).
ADDRESS
Lender's Name
CITY TEL. O
Lender's Address STATE LIC.
I certify that I have read this application and state that the above LICENSE NO. CLASS G.Z�
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 th above- entioned
propertMin tion p rp~osas. SEE REVERSE FOR EXPLANATORY LANGUAGE
A
SIG RE OF APPLICANT OR AGENT DATE