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Home My Public Portal About6158 AVON AVE_Mechanical__ WORKERS' COMPENSATION D.ECLARAT�01\1 APPLICATION FOR PERMIT I hereby affirm that I have a certifi to of-consent to self . orsarcate of ce certified copy Thereof(Sec. 3800, Lab. C tjon Insurance, 76A364C HEATING - VENTILATING - AIR CONDITIONING � 20-0046 DPW 9/88 Policy No. Company F-1 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 / r} '4JOKI .� tion department. ADDRESS (PRINT OR TYPE ONLY) Date Applicant LOCALITY [�G �' 1 /7T NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE CROSS ST. i— (This section neednot be completed the work involved by ABSORPTION UNIT, BTU DISTRICT / PRC SED BY the permit is fororone one hundred dollars ($100) or less.) I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM 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 ATE C IN SP OR'S 51 ATURE 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' with comply with such provisions or this permit shall be deem- ed 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 1 a00 nd Professions Code,and my license is in full force and effect. ✓, ! Itb License Number Lic. Class ,. " O Contractor Date 0 El1 am exempt under Sec. V Plan check fee B.&P.C. for this reason. Date: PERMIT ISSUING FEE $ Signature TOTAL FEE OWNER-BUILDER DECLARATION 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 i Professions Code): I, as owner of the property, or my employees with ADDRESS wages as their sole compensation, will do the work and ACCt a i °a NO. the structure is not intended or offered for sale(Section CITY TEL. ;�3J7 25.013 7044, Business and Professions Code). OWNER �j I, as owner of the property, am exclusively contracting � „L 1 ITEMS EM with licensed contractors to construct the project (Sec- MAIL �� t�, I�DN � �1 � � tion 7044, Business and Professions Code). ADDRESS /�L 25 CONSTRUCTION LENDING AGENCY CITY �,q�f2�C� ]EL. tt; ��;* ;_taE l ! I hereby affirm that there is a construction lending agency for _AAV"' 7t the performance of the work for which this permit is issued CONTRACTOR , CHANGE (Sec. 3097, Civ. C.). ADDRESS Lender's Name (' ?'� CITY TEL. NO. �VrJV '1/26/,Q0Lender's Address 1 certify Pp Lthat I have read this a lication and state that the LICENSE NO. CLASS tedTATE LIC. 7134 1 AN 55 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 the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Sig ature of AW or Agent Dae ©s <4�