HomeMy Public PortalAbout10935 WILDFLOWER RD_Mechanical__ WORKER'S COMPENSATION a certificate
of consent to ��64C PW 9189 APPLICATION FOR PERMIT LIME GREEN
I hereby affirm that I have a certificate of consent to self Insure,
or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.)
Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished,
❑ Certified co y g p BUILDING
departmentPy is filed with the count building inspection FOR APR NTIOR TYPE OOLFILL IN ADDRESS
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS
COMPENSATION INSURANCE
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($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESS BY
I certify that in the performance of the work for which this permit
is Issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws. 0„��
COMPRESSOR,BTU `�
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: if, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL ��
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED-UNIT—
(commencing
USPENDED UNIT(commencing with Section 7000)of Division 3 of the Business and WALL
Professions Code,and my license is in full force and effect.
License Number Lic.Class
Contractor Date , C
Plan check fee C
❑ I am exempt under Sec. Q
BAP.C.for this reason PERMIT ISSUING FEE$ /1 JoO IC.
Date: TOTAL FEE 7 a
Signature Cf
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License Law NAME
for the following reason (Section 7031.5, Business and Professions
Code): ADDRESS
❑ I, as owner of the property, or my employees with wages Eink'
as their sole compensation, will do the work and the CITY '— TEL.NO. -..'-'1'1? �'`�.�. L
structure is not intended or offered for sale(Section 7044, n-ky �J AIN. .a
Business and Professions Code). OWNER
I, as owner of the property, am exclusively contracting IT
with licensed contractors to construct the project (Sec- ADDRESS [i I I L.MI I^,n,
tion 7044,Business and Professions Code). CITY TEL.NO. TOTAL AL 37- 4� 0
CONSTRUCTION LENDING AGENCY _
I hereby affirm that there is a construction lending agency for e�� , y; i�Z ?7 _(LI
the performance of the work for which this permit Is Issued CONTRACTOR
(SBC.3097,CIV.C.).
ADDRESS
Lender's Name
CITY TEL.NO.
Lender's Address . . .. L:s i.
1 certify that I have read this application and state that the above LICENSE NO. LIC.
i 6111 1 AN 10 o��
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 purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
y � S” 2204-c
SIGNATURE OF APPLICANT OR AGENT DATE