HomeMy Public PortalAbout5342 ALESSANDRO AVE_Mechanical__ that
COMPENSATION DECLARATION APPLICATION FOR PERMIT
+I hejeby�tylbffiffirril thaf~I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified cgpyatheredf (Sec. 3800, Lab. C.) 76A364C
,�•��,,� CE-818(REV. 10/81)
Policy No.2 217 Company ✓lfl1G R-t
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 63 l � 4tev
tion department. (PRINT OR TYPE ONLY) ADDRESS 7
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FRO WORKERS' NEAREST
COMPENSATION INSUR CE CROSS ST.
(This section need not be completed if the work invofved 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 of the work for which this J`
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. BOILER, BTU APPROVALS DATE INS E O 'S SIGNAT RE
Date Applicant COMPRESSOR, BTU ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL /
Exemption, you should become 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 io
and Professions Code,and my license is in full force and effect. s 9'
[� p ( EXE 04cl— (;�(� ACCT.
License Number ` 15P3 Class 6 / 010. 3307 �W
20 s:tl.
Contractor Date 1 ITEMS
6d
I am exempt nder Sec. Plan check fee �i f I j A4 20 m
B.&P.C. for this reason PERMIT ISSUING FEE a Q L-HE K 20.5
Date:
Signature CHANGE
TOTAL FEE CHANGE .00
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License , ( I ftG— 1�1?� .r 4/89
Law for the following reason (Section 7031.5, Business and NAME
1
Professions Code): L t�� j AN11a 13
❑ 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 1h V CLL.J�D
❑ I, as owner of the property, am exclusively contracting ITnU
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS 5 ` ArN�� �,
CONSTRUCTION LENDING AGENCY CITYC TEL. NO.
I hereby affirm that there is a construction lending agency forRNAC v ,
the performance of the work for which this permit is issued CONTRACTOR QLJy�0� $
(Sec. 3097, Civ. C.).
ADDRESS 'Z ! Allif
Lender's Name
CITY i ert� CVV t C1�. TEL. NO, �D
Lender's Address WG>> ///�w
I certifythat I have read this application and state that the STATE �—p LIC. p •/
pp LICENSE NO. lJp 3 CLASS D
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
upori the ve-mentio ed property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicantor gent D.te