HomeMy Public PortalAbout4844 ALESSANDRO AVE_Mechanical__ j�,� ' WORKERS COMPENSATION DECLARATION APPLICATION FOR PERMIT
"I hoy c'ffrrm that I have a certificate of consent to self
Ins re or a certificate of Workers Compensation Insurance HEATING VENTILATING AIR CONDITIONING
or a cern fied copy thereof (Sec 3800 Lab C ) 76A364C
CE 818(REV 10/81) r
Policy No Company
Certified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the county building Inspec FOR APPLICANT TO FILL IN BUILDING �w
tion department ADDRESS
(PRINT OR TYPE ONLY)
Dare Applicant LOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS CROSS ST
COMPENSATION INSURANCE
(This section need not be completed if the work involved by ABSORPTION UNIT BTU DISTRICT NO PROCESSED BY
the permit is for one hundred dollars ($100)or less )
AIR HANDLING UNIT CFM
I certify that In the performance ci work for which this f
permit is Issued I shall not employ ny son in any manner
SO OS tobecome subject to the rk s pens WSJ /f� O O APPROVALS DATE IN PE R S SIGNATU E
Date ✓ Appllca t G COMPRESSOR BTt✓/ ROUGH
NOTICE TO APPLICANT If a er making his Certificai of VENTILATION SYSTEM FINAL
Exemption you should beco subject to the Workers
Compensation provisions of the Labor Code you must forth EVAPORATIVE COOLER VALIDA ON
with comply with such provisions or this permit shall be
deemed revoked FURNACE FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business WALL (�
and Professions Code and my license is in full force and effect }
L>"TU AJ
/� ^� U O
nse
LiceN Lic Class X 8 0 4. 1 A t)
Contractor ate — Nh J� $ o • o • e 8
F-1I am exemp under Sec (� ) ° ° 4 U 5 0 LU
Plan check fee 111.
B 8P C for is r ason _ PERMIT ISSUING FEE o • e 4 Q 5 0 Z
Dat TOTAL FEE
Sign u�__.ZNER
O 1 0,02 -87
BUILDER DECL RATI PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor s License ,
Law for the following reason (Section 7031 5 Business and NAME
Professions Code)
❑ I as owner of the property or my employees with ADDRESS
wages as their sole compensation will do the work and
the structure is not Intended or offered for sale(Section CITY TEL NO
7044 Business and Professions Code)
❑ OWNER
I as owner of the property am exclusively contracting G.
with licensed contractors to construct the project (Sec MAIL
tion 7044 Business and Professions Code) ADDRESS 0
i
CONSTRUCTION LENDING AGENCY CITY �E NO
I hereby affirm that there Is a construction lending agency for i
the performance of the work for which this permit Is issued CONTRACTOR120 12, 14C 00
(Sec 3097 Civ C )
ADDRESS 6 , r
Lender s Name
I CITY D TEL NO L
Lender s Address
STATE / LIC
I certify that I have read this application and state that the LICENSE NO p CLASS C z 0
above information is correct I agree to comply with all County
ordma d State laws relating to building construction
an iereby au ize representatives of this County to enter "
on the men one roperty for In pection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
6 -/- 7
Sign re of Applicant or Agent Date `