HomeMy Public PortalAbout9949 WORKMAN AVE_Mechanical__ WORKER'S COMPENSATION DECLARATION +20.0046 DPW 9l69 APPLICATION FOf" PFIRMIT
I hereby affirm that I have a certificate of.consent to self Insure, ?BA384C y LIME GREED;
or copy CIS
thefeiof( Df.seoo LabCCmpeneation Insurance, a certified HEATING-VENTILATING-AIR CONDITIONING
Policy
!.LNo. mpany 7,VS,zj_ COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
❑ Certifi d copy i filed with the county bu g Inspection FOR APPLICANT TO FILL IN BUILDING
d ent. (PRINT OR TYPE ONLY) ADDRESS r
Date' ApplicantLOCALITY
TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTI ICATE OF EXE FROM WORKERS' NEAREST
CROSS ST.
COMPENSATION INSURANCE ABSORPTION UNIT,BTU
(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. o
COMPRESSOR,BTU
Date Applicant VENTILATION SYSTEM APPROVALS DATE INSPECTOR'S SIGNATURE
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH'
Exemptiori,'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 V
LICENSED CONTRACTORS DECLARATION FLOOR BTu 3 d� VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of tfie Business and HEATER: WAL
Professions Code,and my license is in full force and effect.
a_y%4_
I
License Number. Lie.Class OE
Contractor Date C
❑ I am exempt under Sec. ;Plan check fee a
B.&P.C.for this reason i PERMIT ISSUING FEE �I3--
I y� _ C
7'2-
Date: `. TOTAL FEE O a- i i fi MC a
SignatureU.
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT -I-[AL
—[AL U_; = �� 2
I hereby affirm that I am exempt from the Contractor's License Law NAME �
,
for the following reason(Section 7031.5, Business and Professions "f�i=('d
Code): ADDRESS "`
E] •1, as owner of the property, or my employees with wages CHANGE �il'L'
as'their sole coinpensation, will do the work and the CITY TEL.NO.
structure is not intended or offered for sale(Section 7044, r;IIS0."-1 j :' �;1113/92
Business and Professions Code). OWNER f
I, as owner of the property, am exclusively contracting 1.x"'65 j � �•iC-,
1 ❑ MAIL C'1`:: 3°^+
' with licensed contractors to construct the project (Sec- ADDRESS
tion 7044,Business and Professions Code). '
CONSTRUCTION LENDING AGENCY' CIN TEL.NO.
{ I hereby affirm that there is a construction lending agency for CONTRACTO
I _77A 11110.
the performance of the work for which this permit is Issued
R (Sec.3097,Civ.C.).
' ADDRESS '
I lender's Name
clTv TEL.NO.
Lender's Address
I certify that I have read this application and state that the above LICENSE NO: CLLASS
information is corr la gree.to comply with all County ordinances I
and State laws re in9 to building construction,and hereby authorize
representative oft ounty to enter upon the above-mentioned
I property ns e It purposes, SEE REVERSE FOR EXPLANATORY LANGUAGE
i