HomeMy Public PortalAbout8752 BURGHARDT RD_Mechanical__ WORKERS'that
CI have COMPENSATIONDECLARATION
of corse APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self '
insure, or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof ec. 3800, b. C.) 76A364C
J/ CE-818(REV. 10/81)
alit 1_�� ompony z:z -err•
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(mss Z'-
tion department. (PRINT OR TYPE ONLY) ADDRESS P /Date—Applicant LOCALITY
ez
NO, TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
.
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NOPROCESSED BY
the permit is for one hundred dollars ($100)or less.)
I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM r O /•
permit is issued, I shall not employ any person in any manner T•�. x
so as to become subject to the Workers Compensation Laws. BOILER, BTU APPROVALS DATE INSPECTORS SIGNATURE
Date Applicant COMPRESSOR, BTU ROUGH Q-.?z, r
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 7 VALIDATION
with comply with such provisions or this permit shall be 7�oC
deemed revoked. FURNACE: FAU GRAVITY /
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 Cod e,and my license is in full force//a�nd effect. y
License Number`1-02 Lic. Class 7:1 / 1 , U
J K
Contractor ( ate O
N
F-1I am exempt under Sec. d
Plan check fee to
B.BP.C. for this reason PERMIT ISSUING FEE $ us
Date:
Signature TOTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License t ,
Law for the following reason (Section 7031.5, Business and NAME IQ
Professions Code): s�7 8 0.9 A
ADDRESS A
❑ I, as owner of the property, or my employees with � � IL
wages as their sole compensation,will do the work and CITY e s
the structure is not intended or offered for sole(Section U a,/i//¢•
7044, Business and Professions Code). OWNER r• - _ 2 E - 30,50
❑ I, as owner of the property, am exclusively contracting MAIL f s o • e o 0 3 Q 5 0 5
with licensed contractors to construct the project (Sec- ADDRESS ( S C�/Q
lion 7D44, Business and Professions Code). 1227-83
CONSTRUCTION LENDING AGENCY CITY TEL NO:
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.). G p
ADDRESS
Lender's Name
CITY •• TEL. NO.
Lender's Address STATE �f (�
I certify that I have read this application and state that the LICENSE NO. r / .5 34 CLASS (.D — / -
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize rep se atives of this County to enter
u n the above, n j p pert for inspection purpo es SEE REVERSE FOR EXPLANATORY LANGUAGE
52
Signature of Applicont or Agent Data C