HomeMy Public PortalAbout9142 WOOLLEY ST_Mechanical__ WORKER'S COMPENSATION DECLARATION 46DPW 9/89
I hereby,affirm APPLICATION FOR PERMIT LIME GREEN
firm thA7BA364C
t I have a certificate of consent to sett insure, 76A3
or a certificate of Worker's�,Coo�lmp�ensation Insurance, or a certified ' HEATING-VENTILATING-AIR CONDITIONING
Dopy LO ec. L 0D1400'1'
,,Company `I4 S COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
�Certified copy is hereby furnished. �i�/-/a_��
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r_1Certified copy is filed with the u t bull Ing Inspection FOR APPLICANT TO FILL IN ADDRESS Z WctoLL✓E /
department. (PRINT OR TYPE ONLY)
LOCALITY PLE- COY
Date` ApplicantNO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEM ON FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS
' 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($100)or less.) AIR HANDLING UNIT,CFM DISTRICT NO. PROCESSED BY
I certify that in the performance of the work for which this permit
b issued,subject
t not employ any person in any manner so as to BOILER BTU
become sub'ect to the Workers'Compensation Laws.
COMPRESSOR,BTU '�� ��
APPROVALS DATE• INSPECTOR'S SIGNATURE
Date Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER
provisions of the Labor Code,you must forthwith comply with such FINAL _ 2
provisions or this permit shall be deemed revoked. FURNACE: FAUG TY
LICENSED CONTRACTORS DECLARATION FLOOR BTU B-O VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business and HEATER: WALL
Professions Code,andmylicense•is in full force and effect.
License Number ` Lie.Class
® ACCTeJ a
Contracto Date 33503 120.90 C
E3 r a exempt under sec. Plan check fee
1 ITEMS a
B.&P.C.fort reason PERMIT ISSUING FEE$ C
TOTAL' 120 m 90 .�
Oar TOTAL FEE yo CHECi4 120.90
Signature PLAN CHECK APPLICANT a
O NER-BUIL R DECLARATION CHANGE
1 hereby affirm that I am exempt from the Contractor's License Law NAME VCstIC� ■< �N lf�. �r•l]�(-w ,
for the following reason (Section 7031.5, Business and Professions t��`tJ�'► �y �y�y
Code): I ADDRESS � 0000-.0001 7/25/9b
❑ I, as owner of the property, or my employees with wages -t • t o A i
as their sole compensation, will do the work and the CITY of TEL.N( (�r�)�-t-t�( (1 7658 1 AM11-54-.
structure is not intended or offered for sale(Section,7044, r.w
Business and Professions Code). OWNER ., yy i�
❑ n
I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS ( f0 Lige 1 i
tion 7044, Business and Professions Code).
CONSTRUCTCitION LENDING AGENCY CITYrIt voiv
I hereby affirm that there is a construction lending agency for CONTRACTOR P�� ,
the performance of the work for which this permit is Issued
(Sec.3097,Civ.C.). �Q �,
ADDRESS vg 'it Ae
Lender's Name CITY D TEL.�aiK�9 ,�,37 I
Lender's Address STATE / LIC.
I certify that I have read this application and state that the above LICENSE NO. b� CLASS��
Information is correct. I agree to comply with all County ordinances
and State laws relating to building construction,and hereby authorize
r%. RE
lives f this County to enter upon the above-mentioned
p r Ins ection purposes. e� SEE REVERSE FOR EXPLANATORY LANGUAGE
/Lr/(,I
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OF APP TR AGENT DATE