HomeMy Public PortalAbout5325 WELLAND AVE_Mechanical__ f WORKER'S COMPENSATION DECLARATION 20.0048 DPW 9/89
76A364C
I hereby affirm that I have a certificate of consent to self insure, �PPUCATM ®R PERNTLIAAE GREEN
or,a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.)
Policy N_ �a'�Comp. .4AfUZNTV OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished. �/� 3
ECIFICASTEOF
ith the county building inspection i FOR APPLICANT TO FILL IN BUILDING
(PRINT OR TYPE ONLY) ADDRESS [✓�/
Da plicae -� NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
NEAREST
XEMPTION FROM WORKERS' CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
(This section need not be completed if the work Involved by the ASSESSOR
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 (/
become subject to the Workers'Compensation Laws. "< ®O �BQ4 rveeO44 �/_
COMPRESSOR,BTU
APPROVALS DATE INSP R•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 ti
provisions or this permit shall be deemed revoked. J FURNACE: FAU TY
LICENSED CONTRACTORS DECLARATION FLOORBTU O 3 VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect. p
License Num t ,�/ FLIc.Class 0 o D
Cont rat�� 4-9 C
❑ I am exempt un r sec. Plan check fee a
B.&P.C.for this reason PERMIT ISSUING FEE$4;2z/
k
Date: TOTAL FEE
Signature
OWNER-BUILDER DECLARATION PIAN CHECK APPLICANT 6
I.hereby affirm that I am exempt from the Contractor's License Law NAME I I h-• +I - -'-^`
for the following reason(Section 7031.5, Business and ProfessionsC'
ADDRESS
Code): =. r_.i L 7
E] I, 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). OWNE
❑
I
, as owner of the property, am exclusively contracting MAIL `I -Jti J- y.
with licensed contractors to construct the project (Sec- ADDRESS -:q L tj�•_; °`,
tion 7044,Business and Professions Code). _
CONSTRUCTION LENDING AGENCY CITY TEL.NO.
I hereby affirm that there Is a construction lending agency for CONTRALTO
the performance of the work for which this permit is issued
(Sec.3097,Civ.C.).
ADDRESS
Lender's Name
CITY TEL.
Lender's Address
I certify that I have read this application and state that the above LICENSE N zj� CLLA',SS C '�
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 f f 1 pection purposes. r, p SEE REVERSE FOR EXPLANATORY LANGUAGE
1 1// 2—
SIGNAT OF APPLICANT OR AGENT MkTE