HomeMy Public PortalAbout4927 WILLMONTE AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION �Mt�eCDPW 9l89 APPLICATION FOR PERMIT L�MV � GREE[M
I hereby affir.' that I have a certificate of consent to self insure,
or ater(l}icate of Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
copy thereof(Seo.3800 Lab.C.) LI
Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Certified copy is hereby furnished.
❑ FOR APPLICANT TO FILL IN BUILDING �( - M
Certified copy is filed with the county building Inspection PRINT OR TYPE ONLY) ADDRESS I v
department. f
Date ApplicantLOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEARESTCROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU ASSESSOR x p� 3
(This section need not be completed if the work Involved by the MAP BOOK d O PAGE d4P?- PARCEOC256
permit is for one hundred dollars($100)or le4rt
AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work
is issued, I shall not employ any person i BOILER,BTUbecome subject to the Workers'Compens nCOMPRESSOR,BTUAPPROVALS DATE INSPECTOR'S SIGNATURE
Date ApplicaVENTILATION SYSTEM
10
NOTICE OAP LICANT: If, of er makinROUGH17-72„
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such I FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOORBTU d !o 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
Professions Code,and my license is in full force and effect. Ifo
License Number����� Lia Class~ ^`�
010.
Contractor hCow-) �+� aGte ACCTou C
❑ I am exempt under sec. Plan check fee 3303 91.7t
B.aP.C.for this reason PERMIT ISSUING FEE
1 ITEMS C
TOTAL 9-•o 7j�
Date: TOTAL FEE /� Q ILL
Signature CHECK 91070'L
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT CHANGEG
I hereby affirm that I am exempt from the Contractor's License Law NAME 011111. ���
for the following reason (Section 7031.5, Business and Professions nnnr1
❑Code): ADDRESS 0000-0001 $/ 9/9�
I, as owner of the property, or my employees with wages 0
as their sole compensation, will do the work and the CITY TEL.NO. 1764 1 AM 7 e
:23
structure Is not intended or offered for sale(Section 7044, `
Business and Professions Code). OWNER
❑ I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS �”] l pv�
tion 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY^� �� C, t TEL.NO.
I hereby affirm that there is a construction lending,agency for CONTRACTOR 1 �� ,
the performance of the work for which this permit s issued Y1'Q()�/3. �f'� L
(Sec.3097,Civ.C.).
ADDRESS 1 f J_.- S% L�-
Lender's Name �Ly
CITY 1 Q TEL.N 9� 1 _Gj�
Lender's Address
I certify that I have read this applies' n state that the above LICENSE NO. � CLCASS
information is correct. agree t o ly all County ordinances
and State I s relati o buil ' s on,and hereby authorize
repress ti s of s Cou t ent pon the above-mentioned
prop r ins ction p po s. SEE REVERSE FOR EXPLANATORY LANGUAGE
GNATURE OF PPLIC GENT TE