HomeMy Public PortalAbout5016 WILLMONTE AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION 20-0048 DPW 9189 L I \
76A3840 GREEN
I hereby affir�that I have a certificate of consent to self insure, APPLICATION FOR PERMITLIME
or a certificatd of+Worker's Compensation Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING
c ther.eof(Sec.3800 Lab.C.)
Polio0 2 7—Company
panyc ( t i 1(
tw �►9F EBF.
❑ COUNTY O�LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
ified copy is hereby furnished.
C UILDING
Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN ADDRESS J'Cj l 42 !' An t j'v 4c
department. (PRINT OR TYPE ONLY)
1
Date � � Applicant 15 CZ e J�/I• LOCALITY a TYPE OF APPLIANCE OR EQUIPMENT FEE °�
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSSSST. cs
G—
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($100)or less.) AIR HANDLING UNIT,CFM
DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employ any person in any manner so as to BOILER,BTU
become subject to the Workers'Compensation Laws.
COMPRESSOR,BTU
APPROVALS DATE INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL
GAMAI"Y
provisions or this permit shall be deemed revoked. FURNACE: FAURA I
LICENSED CONTRACTORS DECLARATION ` FLOOR BTU V I ATION
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED—UNIT—
(commencing
USPENDED UNIT(commencing with Section 7000)of Division 3 of the Business and WALL I
44
Professions Code,and my license is 16 full force and effect.
License Number/ 7 G a Lie.Class
{+�� I tom/ , AJf s �� �
Contractor y 4.rtJ'� +F SQ l�S /Date 6--30-RS 13133 �'�'I!c C
F1 Plan check fee I am exempt under Sec. I ITEMS a
B.&P.C.for this reason PERMIT ISSUING FEE$ � c L
5`l� OTAL 7y
Date: TOTAL FEE CHEICKCSL405
uAq�t _ 14
a
Signature PLAN CHECK APPLICANT •.-t�rT�i'3i: ,I_II_
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 1� �0— I 12/27 /9-3 r { i
Code): ADDRESS t.0
❑ I, as owner of the property, or my employees with wages 3141'r '( AM 9'-241
as their sole compensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale(Section 7044,
Business and Professions Code). OWNER
❑ 1, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS i (�
tion 7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY C TEL.NO. r C rf
I hereby affirm that there is a construction lending agency for CONTRACTOR ,
the performance of the work for which this permit IE le(Sec.3097,Civ.C.). s issued
ADDRESS id
4
Lender's Name
CITY TEL.NO. '
Lender's Address STATE LIC
.
I certify that I have read this application and state that the above LICENSE NO.` _ , CLASS AU
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
propertyforInns`peccttiio�n� purposes. �} {� SEE REVERSE FOR EXPLANATORY LANGUAGE