HomeMy Public PortalAbout5400 BARELA AVE_Mechanical__ WORtERRS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
1';aery affirm tfsat I have a certificate of content to self
pis{ i?'S3fcvrirtlflcate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a clerttfiortd cppy thereof (Sec. 3800, Lab. C.) 7&&-164CPolley No Company r�i &Ai&+<C //Op CE-818 10/81)
R—Certtfled copy Is hereby fumished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy Is flled with the county building Inspec- FOR APPLICANT TO FILL IN BUAD�
tion departmentSS
(PRINT OR TYPE ONLY)
Date (/`� O f�Applicant LOCALITY
NO. TYPE OF APNANCE OR EQUIPMENT FEE c�
CERTIFICATE OF 17EMPTION F WORKERS' �
ENS
COMPATION INSURANCE
(This section need not be completed If the work In"Feed by ABSORPTION UNIT, BTU MSTRK7 NO. PRoa Sr M BY
the permit Is for one hundred dollars (;100) or less.) /Z((
I certify that In the performance of the work for.which this AIR FIANDtJtJG UNIT, CFM ` (/a
permit Is Issued, I shall not employ any n In any manner
so as to become subject to the Workers mpensatlon Laws. BOILER, BTU Appppvw5 DATE oR s S+cwruRf
ROUGH
Date Applicant BTU r9 a
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FlN.AL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATI N
with comply with such provisions or this permit. shall be
deemed revoked. RJRNACE: FAU
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEALER: SUSPENDED UNIT
'(commencing with Secticn 7000) of Dlvtslon 3 of the Business WALL
and Profbsslohz Code,and my license Is In full force arndd affect. �'
License Numbper ��rLlc. Class�c� , V
ControctorQr,e�//fOfe_f Date 0
O
❑ I am exempt under Sec. LU
Plan check fee
H
B.BP.C, for this reason PERMIT ISSUING FEE
Date:
- 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 M AU
Professions Code): ;24835A
❑ I, as owner of the property, or my employees with ������ ��L �`�
wages as their sole compensation,will do the work and �� AL TEL NO�.� lle # 0 0 o e o 8
the structure Is not Intended or offered for sale(Section
7041, Busthess and Professions Coded OWNER J ° ° 3 Q 5,0
❑ I, as owner of the property, am exclusively contracting 3 Q 50 i
with licensed contractors to construct the project (Sec- MAIL ° ° °
tion 7044, Business and Profeuions Code). ADD d' D et 14A
CONSTRUCTION LENDING AGENCY CITYTEL NO. O 6 1 7�8 6
I hereby affirm that there Is a construction lending agency for '
the performance of the work for which this permit Is Issued CONTRACTOR C
(Sec. 3097, Civ. C.). / ��JJ
ADDRESS �,6^,v f:�
Lenders Name
CITY TEL
Lender's Address U/�✓� �
STATEUC
I certify that I have read this appllcatlon and state that the LKf145E NO. CLASS C� d
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 t v an�flonedroperty for Inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Stg",91911p01conf or Agent Date