HomeMy Public PortalAbout5521 WELLAND AVE_Mechanical__ WORKER'S COMPENSATION
certificate
Of consent to
20.0048 DPW 9/89 APPLICATION FOR PERMIT LIME GREEN,
I hereby affirm that I have a certificate of consent to self insure, 78As64C ,
or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(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.
El Certified copy is filed with the county building Inspection FOR APPLICANT TO FILL IN BUILDING
� �/ /
department. (PRINT OR TYPE ONLY)
Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY ��/�PL Crr
NEAREST
/ �
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. L✓ V r K
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($100)or less.) I AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY
I'certify that in the performance of t' a work for which this permit
is Issued, I shall not employ•any r n in y manner so as to BOILER,BTU
become subject to the Workers'C pen alio WS.
r/Z COMPRESSOR,BTU �"�go®G�
Date / Appiican Y APPROVALS DATE INSP R'S-SIGNAT RE
NOTICE TO APPLICANT: If, of er eking this Certificate of ROUGH
'Exemption,you should become subject o the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith-comply with such FINAL
provisions or this permit shall be deemed revoked. 1 FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION I FLOOR BTU 00 V VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and WALL
,Professions Code,and my license is in full force'and'eeffecct.
License Nu 91 / UC.Class�C0
Coritractor Date �Z_ I , L
Plan check fee
❑ I am exempt under Sec.. II
B.&P.C.for this reason ' PERMIT ISSUING FEE$
Date j TOTAL FEE O LLa
Signature Cr
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License Law NAME �M , -`
for the following reason(Section 7031.5, Business and Professions
e): ADDRESS Q� A sv 1°g r
I; as owner of the property, or my employees with wages C � FD _ t�
as their sole compensation, will do the work and the ` CITY U TEL.NO. 3 q 785 r-?CI t 7='a�'-1
;structure is hot Intended or offered for sale(Section 7044, I ,,,-
Business and Professions Code). I OWNER CELE I 1( I Iv
❑ I,'as owner of the property, am exclusively contracting MAIL / �� I Ti I AI90. 40
with licensed Contractors to construct the project (Sec- ADDRESS _5:52 (/V ,�
tion 7044,Business and Professions Code) . CHECK
CONSTRUCTION LENDING AGENCY CITY TG TEL.NO.
I.hereby affirm that there is a construction Lending it apency for AN, C,IHFNNG,E °130
the performance of the work for which this permis issued CONTRACTOR
(Sec.3097,Civ.C.). i
ADDRESS `j ,'J i-►ia? 5 I
Lender's Name �D Wa 'moi/ �/��� F,`� Q/� ) i_I,I'"I_C-1 1 L/ 6/922
CITY 2 So .C/ / 9I26EL.NO. `Y 70 7 242i AM �:3_
Lender's Address.
I cert' that I hav read this application and state that the above ILCENSE NO. �� LIC.
G.-
info he n is cor ct. I agree to comply with all County ordinances
an St a laws re ting to building construction,and hereby authorize
re es- tatives o th County to enter upon the above-mentioned
pr p ty or insp on purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
—Z6 —9?
611 NA 0 APPL RT OR AGENT DATE