HomeMy Public PortalAbout5342 BARELA AVE_Mechanical__ DEC
WORKERS'COMPENSATION
cerci cats of coo" APPLICATION FOR PERMIT
�. I herfsb�r Fffkm that I have a certificate of consent to self
.7.'4'lnsure, ora certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec. 3800, Lab. C.) 7&k364C
CE-618(REV. 10/,8Y)
Pollcy No. Company
❑
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
Wtion department. (PRINT OR TYPE ONLY) J /
Date Applicant LAITY C Gl/�, �
NO. TYPE OF APPLWJCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' � E�
COMPENSATION INSURANCE
(This section need not be completed If the work Im rowed by ABSORPTION UNIT, BTU DiyTRK7 NO. y
the permit Is for one hundred dollars (:100)or loss.) AIR HANDLING UNIT,CFM
O�
I certtfy that In the performance of the work for which this
permit Is Issued, I shall not employ any person In any manner
as to become sublect to the Work C ipen,IsaVon Laws. BOILER, BTU APPRCVAr.S DATE ars SXR4.A
17 � ,�l �' BTU ROUGHOf
i
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- EVAPORATfVE COOLER VALIDA
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FA GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED IINIT
'(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code,and my license Is In full force and effect. p�
O
License Number Llc. Class 04
Poll'.
Co21 4 2 7 A O
V
Contractor Date P El .4 1
I am exempt under Sec. ooloo . g
Plan check fee I e - 26,50 d
B.BP.C. for this reason'
Date: PERMIT ISSUING FEE $ d ° o 626506
—
I
TOTAL FEE r 14122.91-88
51 G rwtu re
OWNER-BUILDER DECLARATION �CH�A>��T
I hereby affirm that I am exempt from the Contractor's License D
Law for the following reason (Section 7031.5, Busineu and ,B1?14
Professions Code): n ^�/
❑ I, as owner of the property, or my employees with ADDRESS Z-.A YZ--
wages as their sole compensation,will do the work and /
the structure Is not Intended or offered for sale(Section CIfY L L TEL
704", Business and Professions Code).
❑ OWNER
I, aMAIL
s owner of the property, am exclusively contracting
with licensed contractors to construct the prolect (Sec- DL)itf55 0,"zM i4 V--'---'tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCYr L NO 70C C��l
I hereby affirm that there Is a construction lending agency for G C� Poo.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 Addreu
STATE uc
I certify that 1 have read this application and state that the U NSE NO. 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
` �por a above-nVDflo2ad progpVy for Insp?pn purpd ' SEE REVERSE FOR EXPLANATORY LANGUAGE .
�joEf
Slgrfaturo of Applicant or Agent Date