HomeMy Public PortalAbout6056ALESSANDRO AVE_Mechanical WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT
I he�eb�y affirm that I have a certificate of consent to self �
insure, or a certificate of Workers' Compensation Insurance, 76A364C HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec. 3800, Lab. C.)
CE-818(REV. 10/81)
Policy No``�%eft Ck? ompany �T.CSS c lJ�
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Pol
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. ADDRESS ,5 I
(PRINT OR TYPE ONLY)
�-�-� LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
`Dote`Ili2—kf!R�pplicantc:)�
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST ,
COMPENSATION INSURANCE CROSS ST.
ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY
(This section need not be completed if the work involved by
the permit is for one hundred dollars($100)or less.) AIR HANDLING UNIT, CFM (✓/�I^ ^ .��
1 certify that in the performance of the work for which this �/L j
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
Date Applicant COMPRESSOR, BTU O ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL o y--
Exemption, you should become subject to the Workers' t
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 GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPE U j�
HEATER: WALL
(commencing with Section 7000) of Division 3 of the Business
and Professions Code,and my license is in full force and effect.
(� ICL
License Number�q C R 192kLic. Class U
Contractor C-)4 12-A Date �
❑ I am exempt under Sec. uul
Plan check fee
BAP.C. for this reason PERMIT ISSUING FEE $
Date:
Signature TOTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 7 6'5 5 A
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and NAME 0 0 0 0 8
Professions Code):
❑ I, as owner of the property, or my employees with ADDRESS 2 -.- 20.50
wages as their sole compensation,will-do the work and CITY TEL. NO. 'o o 0 2 Q 5 0 6
the structure is not intended or offered for sale(Section
7044, Business and Professions Code). n ,OWNER 1 21 6�8 3
1�
❑ I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL n ,
tion 7044, Business and Professions Code). ADDRESS f.
CONSTRUCTION LENDING AGENCY CIT \C TEL. NO. p\
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 %
v�
Lender's Name a
CIT TEL. NO .
Lender's Address
I certifythat I have read this application and state that the STATE LIC.
pp LICENSE NO. Q 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 the ove-m ntioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date