HomeMy Public PortalAbout9627 WOODRUFF AVE_Mechanical__ ItIOPiKER'S COMPENSATION DECLARATION- �8A36aOPW 9/890APPLICATION FOR PERMIT LI E GREEN
I hereby-affirm that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a cert(fied ,. HEATING-VENTILATING-AIR CONDITIONING.
copy thereof(Sec.3800 Lab.C.)
Policy No. Company COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
BUILDING
❑ Certified copy is filed with the county building Inspection FOR APPLICANT TO FILL IN ADDRESS //,
department. (PRINT OR TYPE ONLY)
Date ApplicantLOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST
CERTIFICATE OF EXEMPTION FROM 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($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
is issued, I shall not employany pers in any manner so as to BOILER,BTU 61 D
become subject to the Workers'Compe tion Laws.
i
/ff COMPRESSOR,BTU
I / S APPROVALS DATE INSPECTOR'S SIGNATURE
Date Appli nt VENTILATION SYSTEM
NOTICE TO APPLICANT: If, r making this Certifi ate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code, you must forthwith comply with such FINAL
provisions or this permit shall be deemed revoked. FURNACE: FAU G I / O VALIDATI N
LICENSED CONTRACTORS DECLARATION FLOOR. BTU (!�
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and HEATER: WAL
Professions Code,and my license is in full force and effect.
L ,
License Number LID.Class f u vi`i%�J
e,' �� SFS ACCToa n
Contractor
❑ I am exempt under Sec. Plan check fee 3303 147 e70 a
B.BP.C.for this reason ' PERMIT ISSUING FEE$ Ev
1 ITEM
Date: TOTAL FEE 70 TOTAL 1•x-7 m 70
CHECK 147.70 a
Signature CZ
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT CHANGE .00
I hereby affirm that I am exempt from the Contractor's License Law NAME /JA , e
for the following reason(Section 7031.5, Business and Professions �y o¢
Code): ADDRES r 0000-0001 11/ 8/95
❑ I, as owner of the property, or my employees with wages C.M �f o
as their sole compensation, will do the work and the CITY L' TEL.N0.61 � 3� 3217 1 f11120-11
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 , 4
tion 7044,Business and Professions Code). CITY TEL.NO. avf
CONSTRUCTION LENDING AGENCY
1 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.
Lender'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
repro ntatives of t •s County to enter upon the above-mentioned
pro y for inspe i n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
APPLI GENT t TE