HomeMy Public PortalAbout9921 BROADWAY_Mechanical__ affirm that
COMPENSATION DECLARATION APPLICATION FOR PERMIT
�-1 h ef5y affirm that I have a certificate of consent to self
irl tarp cerfticate ofrWorkers' Compensation Insurance, 7cnab4c HEATING VENTILATING AIR CONDITIONING
or a cerfifieedd.ccopy thereof(Sec. 3800, Lab. C.) CE-818(REV. 10/8I)
Policy No0�D �a3 /(py y �Drs�_eT COUNTY OF LOS ANGELES _ BUILDING AND SAFETY
rtified copy is hereby furnished.
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BDDRESS
tion department.
deeparpttment. (PRINT OR TYPE ONLY)
Date 47—Z
Applicant 4i 4- LOCALITY
NO, TYPE OF APPLIANCE OR EQUIPMENT - FEE
6111la-
CERTIFICATE OF EXEMPTION FROM WORKER$'�/JCJ NEAREST '
COMPENSATION INSURANCE CROSS ST.
(This section need not be completed if the work Involved by ABSORPTION UNIT, BTU DISTRICT NO. CESSED 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, t shall not employ any person in any manner '
so as to become subject to the Workers'Compensation Laws. BOILER, BTU APpPOVALS DATE INS/ClOR'S SNATURE 14
Date Applicant / COMPRESSOR, BTU f�'r 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 VALIDATI N
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU G VITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED—UNIT—
,(commencing
USPENDED UNIT—'(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code,and my license is in full forcee nand effeecct. -� /J -a 1 / O
License Nuum�bera/UjoJ�d.,�icnCloss QA� /
Contracfcf/l/r7 -
V
❑ I am exempt under Sec. d
Plan check fee H
B.BP.C. for this reason' - PERMIT ISSUING FEE Q 5Q r� Z
Date: #
TOTAL FEE O 'I • 4 4,5
Signature •
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
• • • 4'450
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and NAME , 0 a 26-860 6-8 6
Professions Code):
❑ I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation, will do the work and -
CITY TELNO.
the structure is not intended or offered for sale(Section .
❑
7044, Business and Professions Code).
OWNER
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL a ,�j r•�Q Q/LU�
tion 7044, Business and Professions Code). ADDRESS (J
CONSTRUCTION LENDING AGENCY ❑n !i A�r� TEL NO.,
I hereby affirm that there is a construction Lending agency for L: l/�
the performance of the work for which this permit is issued CONTRACTOR O+ �� Ne G '
(Sec. 3097, Civ. C.). '
rADDSS 0 ��X ��. Q 46
+
Lender's Name
Lender's Address �' e � TEL. NO.• /J/ LICcertify that have read this application and state Ihat the E NO. p1 Q Q (p p2/ TICCLAS - -
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
u onto above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
f&/, "P6 -
Signature of Applicant o i Dote