HomeMy Public PortalAbout4919 WILLMONTE AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 2ooD4sDPW s,es APPLICATION FOR PERMIT LIME GREEN
78A364C
I herebyoffiren tha4 I have a certificate of consent to self Insure, I
or a certificate of,Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thfyreof(Sec.9800 Lab.C.)
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Policy No. Company I COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
❑ BUILDING 'J
Certified copy is filed with the county building inspection FOR APPLICANT
TYPE ONLY)
IN ADDRESS06
department.
LOCALITY
Date Applicant INO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS ST.
COMPENSATION INSURANCE
ABSORPTION UNIT,BTU ASSESSOR �y
(This section need not be completed if the work Involved by the I MAP BOOK PAGE4# 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.
COMPRESSOR,BTU
G'C f7 Ca APPROVALS DATE INSPECTOR'S'SIGNATURE
Date' Applicant �r%�its VENTILATION SYSTEM
NOTICE TO APPLI ANT: If, after making this Certificate of I ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER --"
provisions of the Labor Code,you must forthwith comply with such FINAL S`
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 with Section 7000)of Division 3 of the Business and j( WALL
Professions Code,and my license is in full force and effect. ,
I Lr
License Number 12 Lfc. ACCT.g
J. 3307 50.556-
Contractor /R7/ ? Dat C O
❑ �— Plan check fee i i TEND V
I am exempt under Sec. I
a. C TOTAL m5 5'o
B.&P.C.for this reason PERMIT ISSUING FEE Ir-
CHECK 50n55
(� 3 TOTAL FEE
Z, -]Z
Signature CHANGE -00 n.
OWNER-BUILDER DECLARA ION PLAN CHECK APPLICANT Z
I hereby affirm that I am exempt from the Contractor's License Law NAME & 4 5. O , OO�lQ_�CICJf /1(/�iw
for.the following reason(Section 7031.5, Business and Professions
e): ADDRESS 8241 1 AMID 1
8Co
I, as owner of the property, or my employees with wages f
as their sole compensation, will do the work and the CITY�— A TEL.NO. f!
structure is not intended or offered for sale(Section 7044, It T .2
Business and Professions Code). OWNER
❑ I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS
tion 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TEL.NO.
I hereby
eby affirm that there is a construction lending agency for CONTRACTOR r ,
t
(Sec.3097,Civ.C.).he performance of the work for which this permit Is Issued %
ADDRESS Y �
Lender's Name
II CITY_!�-a Iy t i11C/f TEL.N 1 �•.2
Lender's Address
Il certify that I have read this application and state that the above LICENSE NO. CLCASS
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
SIGNATURE OF APPLICANT OR AGENT DATE I