HomeMy Public PortalAbout4943 WILLMONTE AVE_Mechanical__ DECLARATI
WORKER'S COMPENSATION
ate of consent to �6M64C DPW 9/89 APPLICATION FOR PERMIT LIFE GREEN
I hereby affirm Chat'I Flavb a certificate of consent to self insure,
or a certificate of Worker's Compensation Ingurance, or it certified • ' HEATING-VENTILATING-AIR CONDITIONING
copy ther (Seb.3800 Lab.C.)
Policy o. G `l�bmpanyCOUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ ertified copy is hereby furnished.
BUILDING /
Certif' d cop is tiled with the county uil ' inspection FOR APPLICANT TO FILL IN ADDRESS
/
merit (PRINT OR TYPE ONLY)
Date G Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST
CERTIFICATE OF EXEMPTION OM WORKERS' CROSS ST.
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($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to I BOILER,BTU
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: S DED UNIT
(commencing with Section 7000)of Division 3 of the Business and ALL Y� U
Professions Code,and my license Is in full force and effect.
License Number 6�Z' ' LID.Clas3
Contractor a+--+ Date
/ �i' , C
❑ Plan check fee CI am exempt under Sec. a:
B.BP.C.for this reason PERMIT ISSUING FEE$ 2'7 V
Date: TOTAL FEE 3 -0 Wd
Signature PLAN CHECK APPLICANT
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):
e): ADDRESS �+/'.
1, as owner of the property, or my employees with wages ACCTo4
as their sole compensation, will do the work and the CITY TEL.NO. �q n � n90
structure is not intended or offered for sale(Section 7044, � 3
Business and Professions Code). OWNER 4 3301 ITEP18❑ I, as owner of the property, am exclusively contracting MAIL TOTAL 53-9113
with licensed contractors to construct the project (Sec- ADDRESS ���
tion 7044,Business and Professions Code). CITY �L ?', / /9�[ (%� TEL.NO. —3� CASH � o9d
CONSTRUCTION LENDING AGENCY CHANGE
I hereby affirm that there is a construction lending agency for CONTRACTOR CHANGE .00
the performance of the work for which this permit Is issued !�
(Sec.3097,Civ.C.).
ADDRESS
Lender's Name 1117Jp 0000-0001 10/16/95
MSTATE
/�0� �/ TEL.NO. �Z 2013 1 At 1 9"C`t
Lender's Address LIC.
1 certify that I have read this application and state that the above CLASS j�uo;eq G
information is correct. I agr to comply with all County ordinances
and State laws relating Iiding construction,and hereby authorize
represent ' es oft ' ounty to enter upon the above-mentioned
prop or ins c' n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
NATURE OF AP CANT OR AGENT 13,012