HomeMy Public PortalAbout6133 AVON AVE_Mechanical__ COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm That I have a certificate of consent to self
Insure or a certificate of Workers Compensation Insurance
or a certified copy thereof (Sec 3800 Lab C 76A364C HEATING - VENTILATING - AIR CONDITIONING
)
CE 818(REV 10/81) r
Policy No Company _ - COUNTY OF LOS ANGELES BUILDING AND SAFETY
Pol
Certified copy is hereby furnished
Certified copy is filed with the county building inspec FOR APPLICANT TO FILL IN BUILDING '
tion department / (PRINT OR TYPE ONLY) ADDRESS
Date V`�°� a t Applicant ` LOCALITY T �I
111— NO TYPE OF APPLIANCE OR EQUIPMENT FEE /
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST
COMPENSATION INSURANCE CROSS ST
(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 )
I certify that in the performance of the work for which this AIR HANDLING UNIT CFM �/ Y
permit is Issued I shall not employ any person in any manner V 000
so as to become subject to the Workers Compensation Laws BOILER BTU APPROVALS DATE INSjE OR SIGN URE
Date Applicant f 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 VALIDATION
with comply with such provisions or this permit shall be
deemed revoked FURNACE FAU VIT
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED UNIT
—
(commencing WALL
with Section 7000) of Division 3 of the Business }
and Professions Code and my license is in full force and effect
License Number P8HGQQ Lic Class_ (Oj
^ ,
Contractor f t/ Date
V
I am exempt under Sec 7 b 11 A us
Plan check fee d
B 8P C for this reason Z
Date
PERMIT ISSUING FEE $ # o o • • • $
Signature TOTAL FEE
OWNER BUILDER DECLARATION PLAN CHECK APPLICANT i•'O 3 Q 5 0
j hereby affirm that I am exempt from the Contractor s License , • o o 3 Q 5 04
Law for the following reason (Section 7031 5 Business and NAME
Professions Code) 0 8, 1
2-87`$7
❑ 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 SOT-0
with licensed contractors to construct the project (Sec MAIL 3� ^
tion 7044 Business and Professions Code) ADDRESS ower"
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 )
z
ADDRESS Iaa W r `
Lenders Name
�a7
Lender sAddress CITY TEL NOSTATE LIC
- - `-
I certify that I have read this application and state that the LICENSE NO pL CLASS Ca'�
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
i�jonn the abg:,t
ntioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date