HomeMy Public PortalAbout6237 AVON AVE_Mechanical__ c. WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers' Compensation Iksurance, HEATING - VENTILATING - AIR CONDITIONING
orMr led co y thereof (Sec. 3800, Lab. C.) 76A364C
'' , �6 CE-818(REV. 10/81)
Po ic��CompanyCOUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is hereby furnished_.
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
do d rtment. 9A&_"
(PRINT OR TYPE ONLY) ADDRESS/l
Date Applicant `' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY`
CERTIFICATE OF EXEMPTION FR M WORKERS' NEAREST
COMPENSATION INSURANCE . CROSS ST. deA✓
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROC SED 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
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 INSPECTOR'S SIGNATURE
COMPRESSOR, BTU ROUGH
Date Applicant
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 O GRJT
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
and Professions Code and my license is in ful or a and effect,
License Number Lic. lass 41
i
Contractor &Otto
❑ 1 am exempt under Sec. LU
Plan check fee
B.&P.C. for this reason'
Date: PERMIT ISSUING FEE $
TOTAL FEE
Signature
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
Professions Code):
DI, as owner of the property, or my employees with ADDRESS kti n g
wa es as their sole compensation,will do.the work and
thestructure is not intended or offered for sale(Section CITY TEL. NO. al_'{I
7044, Business and Professions Code). TTPMC
OWNER A J t
❑ I, as owner of the property, A
am exclusively contracting f-= r
IA
with licensed contractors to construct the project (Sec- MAIL �� L. :37 = 00
tion 7044, Business and Professions Code). ADDRESS4�1t.,e _;t, l;l:
CONSTRUCTION LENDING AGENCY I`C*K
CITY=J�y,A/ I� TEL. NO.
v' -��,"`iii 'CHANGE
i^
I hereby affirm that there is construction lending agency for c.�t{)'�(3� t�) ;
the performance of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.). / 01/� / `fes i
Lender's Name ADDRESS �/ l� /\i /�0� €fl)lei—f i(;{F iq S ?i71.`
CITY �� TEL. NO. S! �.��`t i. SiiFtle_`r
Lender's Address G�If//
STATE LIC.
I certify that I have read this application and state that the LICENSE NO. CLASS'�Z�'_
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
n
�entionederty for inspectio purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
l
Signature of Applicant or Agent Oate