HomeMy Public PortalAbout5232 WILLMONTE AVE_Mechanical__ W�RKER'SCOMPENSATION DECLARATION �PW9/89 APPLICATION
FOR
® ���{I��II�� LIME.
I herebyefftrin that I have'a certificate:of consent to self insure, 6 o L awe AW m Eelf �l
or a chereof( ec.worker's Compensatton Insurance, or a certified HEATING-VENTILATING-AIR CONDITIONING- 1 I
GREEN
copy thereof(Sec.3800 Lab.C.). u
Policy No. Company COUNTY OF LOS ANGELES DEPT'OF PUBLIC WORKS BUILDING AND SAFETY DIV.
0 Certified copy is hereby furnished:
❑ Certified co Is filed with the conn buildinginspection FOR APPLICANT TO FILL IN BUILDING ��
departCnt!I P (PRINT OR TYPE ONLY) ADDRESS
! LOCALITY
Date Applicant NO. TYPE.OF APPLIANCE OR EQUIPMENT FEE
NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST.
COMPENSATION INSURANCE' ABSORPTION UNIT,BTU
his section need,not tie 'completed If the work Involved b the ASSESSOR �
R P Y. MAP BOOK P/1GE�6. 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 Cf
APPROVALS DATE INSPECTOR'S SIGNATURE'
Date Applicant, VENTILATION SYSTEM
NOTICE TO APPLICANT: 1f, 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 I I 2
provisions or this permit shall be deemed revoked. FURNACE: FAU G VI - I f��
h 1A_J
LICENSEDDONTRACTORS DECLARATION / FLOOR BTU �(.� VAEIDATIO
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 forbw and effect.
License Number LID.Class
G
Contractor Date ACCT D'a C
p. Plan check. Jee = 1226239.
I am exam t-under Sec. C.
B.&P.C.for this reason PERMIT:ISSUING FEE
i TEMS• F
Date: TOTAL FEE . TOTAL b'5 13
Signature ' CH
�+
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT CHEtr UZZ.1" y 6
I hereby affirm Ahat I am exempt from the Contractot's License L'aw'' NAME +� CHANGE ,rail
for the following reason (Section 7031.5, Business and'Professions v� A' �+ Al,l�/10
Code): p�'
® ADDRESS SQ'3 Z `u i L�h,O Jq R
I,:as owner of the property, or my employees.,with wages r -+
ds their=sole compensation, will do the-work and the CITY' t TEL.NO. 1313t?0-0I1001 5'14193
structure is not intended or offered for sale Section 7044, �� �l�L �' I�`yD'��)7 *7l D�
( -�M .}+ r1 U� 7
Business and Professions Code). OWNER ✓ U N ,f,'�/t�/s ft i ,i�
O 1 rii s
❑ 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'T���� C ;'T TEL.NO. )�.'y®�.a11
I hereby affirm that there is•a construction lending agency for CONTRACTOR
the performance of the work for which this'permit is Issued
(Sec.3097,Civ.C.). -
ADDRESS
Lender's Name
CITY TEL.NO.
"L'ender's Address STATE LIC.
I certify that I have read this application and state that the above LICENSE NO. CLASS
Information is correct. I agree.to comply with all County ordinances
And State laws relating to building construction,and hereby authorize "
"epresentatives of this County to enter upon the above-mentioned
pr rty or Inspection purpose " SEE REVERSE FOR EXPLANATORY LANGUAGE
UNATURE OF APPLICANT OR AGENT DATE ,