HomeMy Public PortalAbout5443 WELLAND AVE_Mechanical__ ,� APPLICATION FOR PERMIT WORKER'S COMPENSATION DECLARATION �W64CPW9189 ���,.�j� GRr�E��
41 herebyaffrm that I have a certificate of consent to self insure, , U
or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING7.Alii CONDITIONING
copy thereof(Sec.3800 Lab.C.)
Policy No.20 10 Comoanv_Rq_"JL, COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Y
❑ Certified copy is hereby furnished.nt!I\Certified co Is tiled with the count buildin Ins ection FOR APPLICANT TO FILL IN BUILDING departmey g p (PRINT OR TYPE ONLY) ADDRESS
LOCALITY T �+
Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE �
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS
COMPENSATION INSURANCE OR
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($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
Is issued, 1 shall not employ any person in any manner so as to BOILER.BTU
become subject to the Workers'Compensation Laws. jet t s�C.J
COMPRESSOR,BTU11
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY / V
LICENSED CONTRACTORS DECLARATION FLOOR BTU 1 t0 O VALIDATION
1 hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED-UNIT-
(commencing
USPENDED UNIT(commencing with Section 7000)of Division 3 of the Business and HEATER: WALL
Professions Code,and my license is in full force and effect.
1
License Number 1:163
1gd-13 Lic.Class
Contractor (�-- I eG T&X-1 Date `4 � 4_C?5 ,
F-1I am exempt under Sec. Plan Check fee __ _ F
t>� _ L
B.&P.C.for this reason PERMIT ISSUING FEE$ _7
Date: TOTAL FEE �'• lj = -�r.; - L
_ 0
Signature G
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT :-' _ 52- 952
I hereby affirm that I am exempt from the Contractor's License Law NAME:"-A
for the following reason(Section 7031.5, Business and Professions
Code): ADDRESSl�1is`
❑ I, as owner of the property, or my employees with wages 77
as their sole compensation, will do the work and the CITY) TEL.NO.
structure is not intended or offered for sale (Section 7044, -t-1-••t_ fes.. ftilr
Business and Professions Code). OWNER ---_
JJ
❑ I, as owner of the property, am exclusive) contracting i 11 �yi.
P P Y. Y 9 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 CONTRACTOR /p , ,
the performance of the work for which this permit is issued 1/�
(Sec.3097,Civ.C.). ,
ADDRESS
Lender's Name
CITY TEL.NO-357__53
O.357_
Lender's Address STATE7G��� LIC. ! O
I certify that I have read this application and state that the above LICENSE NO.as�� CLASS(i
information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
repress tatives of this County to enter upon the above-mentioned
pro a for inspe tj n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
��
SI RE OF APPLICANT ORA NT DATE