HomeMy Public PortalAbout5538 ALESSANDRO AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self
*Msure. o 'b tegificote of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
of-lf�_ (copy thereof (Sec. 3800, Lab. C.) 76A364C
�+� CE-818(REV. 10/81)
Policy No. Company_ Z/�
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
/p�►L Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING a
mon department.. J )� jj (PRINT OR TYPE ONLY) ADDRESS
Date Applicant z;,1,4 0 IJ/ Cb F LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF"EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE' CROSS ST. /00
(This section need not be completed if the'work involved by ABSORPTION UNIT, BTU DISTRICT NO. i PROCE BY
the permit is for one hundred dollars ($100)or less.) {U(/
I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM �J1
permit is issued, I shall not employ any person in any manner v
so as to become subject to the Workers'Compensation Laws. BOILER, BTU APPROVALS DATE INS CT 'S SIGNATURE
DateApplicant COMPRESSOR', BTU ROUGH 2S
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 I N
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 liceHEATER:'
nsed under provisions of Chapter 9 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.
License Number 4Ol VO Lic. Classa r U
Contractor Datep.-
F-1I am exempt under Sec. LU
Plan check fee CL
B.&P.C. for this reason PERMIT ISSUING FEE $ S�
SignatureTOTAL FEE
OW -BU DECLARATION PLAN CHECK APPLICANT J ✓�{ L T C
I hereby affirm t I am exempt from the Contractor's License f� , I Q 2 5.-6a 8 8
Law for the following reason (Section 7031.5, Business and NAME
Professions Code): ;2 Q 9,&3
❑ I, as owner of the property, or my employees with ADDRESS C�D�` � ,i .o c 3 Q 5
wages as their sole compensation,will do the work and CITY l ( � TEL. NO.
the structure is not intended or offered for sale(Section �T'f7f
7044, Business and Professions Code). C o a o 30,5 0 63
OWNER /��
❑ I, as owner of the property, am exclusively contracting ��!�—e. I Q,2 5i--88
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS C"
CONSTRUCTION LENDING AGENCY CITY TEL. NO.
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name
CITY TEL. NO.
Lender's Address
STATE �/ LIC.
I certify that I have read this application and state that the LICENSE NO. L �/� Ua 7 CLASS
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
upon t above-ma„ption property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
C /-0 C
Si ature o Applicant or Agent Date