HomeMy Public PortalAbout4816 WILLMONTE AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 20.0048 DPW 9189 APPLICATION FOR PERMIT LIME GREEN
I hereby affirm that I have a certificate of consent to self insure, 76A3fi4C
or a certificate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Sec.3800 Lab.C.)
Policy No. Company I I
COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
E•, Certified copy Is hereby furnished.
❑f'-Certified copy is filed with the county building Inspection FOR APPLICANT TO FILL IN BUILDING ss t� (,eJt
�fepartment. (PRINT OR TYPE ONLY)
Date ApplicantLOCALITY �' C
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
4.
NEA
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS Sr. �-
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($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY
I certify that In the performance of the work for which this permit �p
is issued, I shall not employ any person In any manner so as to I BOILER,BTU eT Gy6��
become subject to the Workers'Compensation Laws. i D
1 r ' COMPRESSOR,BTU '
Data F� A-L Applicant C 4 C� f VENTILATION SYSTEM APPROVALS DATE INSPECTOR'S SIGNATURE
NOTICE TOA PLICANT: If, after making thi Certificate of -ROUGH
Exemption,you should become subject to the Workrs'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL - f�
provisions or this permit shall.be deemed revoked. FURNACE: FAU AZ GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
z /� e-o VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL I
Professions Code,and my license is in full force and effect.
I
License Number ('7 +'7 ( Lic.Class
`q C
Contractol(o///��01 divent Date 2 r
L
❑ I am exempt under Sec. Plan Check fee a
B.&P.C.for this reason 37 `r PERMIT ISSUING FEE$ I-
Date: TOTAL FEEV
p0.
Signature PLAN CHECK APPLICANT Z
OWNER-BUILDER DECLARATION
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 ! r
H="'
I, as owner of the property, or my employees with wages L °g
as their sole compensation, will do the work and the CITY TEL.NO. 3307 25.013
structure is not intended or offered for sale(Section 7044, _
Business and Professions Code). OWNER ER ( } k_ I it
❑ I, as owner of the property, am exclusively contracting ADD // r W t f !( L'i j L 25- 00
with licensed contractors to construct the project (Sec- RESS �l b l` OL, /E' I 3
tion 7044,Business and Professions Code). i I f i s'.4 ft a:-.D
CONSTRUCTION LENDING AGENCY CITY 6- 4a Cr, TEL.NO. xv LJ`g
I hereby affirm that there is a construction lending agency for // t A CHANGE e131�
It performance of the work for which this permit s Issued CONTRACTOR L` f(C r�
(Sec.3097,Civ.C.). � j� I /
ADDRESS 3 'c( �� f`/ �� I I[!'L-Vfirl i f 2/9'
Lender's Name
ESTATE
,SI EL.NO.�1$' D.
J7s3+1 1 AN ya,f
Lender's AddressI
LIC. e1 certify that I have read this application and state that the above O. V CLASS
information is correct. I agree to comply with all County ordinances
o,aTd State laws relating to building construction,and hereby authorize
r presenta'ves of this Cc my to enter upon the above-mentioned
ropert r' _ e 'o rposes. i , r SEE REVERSE FOR EXPLANATORY LANGUAGE
NA RE OF AP "CANT OR AGENT D)VrE