HomeMy Public PortalAbout5514 ALESSANDRO AVE_Mechanical__ t
WORKERSCOMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that
that I have a certificate of consent to self
Insure or a certificate of Workers Compensation Insurance HEATING VENTILATING AIR CONDITIONING
or a certified copy thereof (Sec 3800 Lab C ) 76A364C
I CE 818(REV 10/81)
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 J /
tion department (PRINT OR TYPE ONLY) ADDRESS
Date Applicant LOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST f
COMPENSATION INSURANCE CROSS ST
' ABSORPTION UNIT BTU
(This section need not be completed IF the work Involved by DISTRICT NO PROLES D BY�
the permit Is For one hundred dollars ($100)or less)
I certify that in the performance of the work for which this AIR HANDLING UNIT CFM L O
permit Is issued I shall not employ any person In any manner
so as to bec me sublect to the Workers C mpen Ion LOWS BOILER BTU APPROVALS DATE INSPE710 SIGNATURE
Date pplicant J COMPRESSOR BTU ROUGH i
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 VALIDATI N
with comply with such provisions or this permit shall be
deemed revoked FURNACE FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
i I hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED-UNIT-
(commencing
USPENDED UNIT(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code and my license is In full force and effect }
D o
License Number Lic Class , V
OC
Contractor Date O
F—
❑ I am exempt under Sec _ S!
Plan check fee i CL
N
B 8P C for this reason PERMIT ISSUING FEE $ Z
Date
Signature TOTAL FEE 2 0 7&6 A
OWNER BUILDER DECLARATION PLAN CHECK APPLICANT _
I hereby affirm that I am exempt from the Contractor s License Poo. o • • • 0 8
Law for the following reason (Section 7031 5 Business and NAME o - 2050
Professions Code) t
❑ I as owner of the property or my employees with ADDRESS
wages as their sole compensation will do the work and2 0j Ov
the structure is not intended or offered for sale(Section CITY TEL NO o • o
7044 Business and Professions Code) r
UWNER � �}�f O 92 S.a 8 i
Elas owner of the property am exclusively contracting 1 V
with licensed contractors to construct the project (Sec MAIL ^ '
tion 7044 Business and Professions Code) ADDRESS L /V
CONSTRUCTION LENDING AGENCY CITY' TEL NO e7 rN 1 J
I hereby affirm that there is a construction lending agency for pool performance of the work for which this permit Is issued CONTRACTOR
(Sec 3097 Civ C )
ADDRESS
Lender s Name
CITY T
Lender s Address
STATE / V LIC
I certify that I have read this application and state that the LICENSE NO CLASS
above information is correct I agree to comply with all County
ordinances and State laws relating to building construction
and here y outhoriize r resentatives of this County to enter
upon th a ve rrned r for Inspti n purpo�es SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date
f