HomeMy Public PortalAbout6022 BURTON AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self APPLICATION FOR PERMIT
insure, or a certificate of Workers' Compensation Insurance, As64C HEATING - VENTILATING - AIR CONDITIONING
7a
or a certified copy thereof (Sec. 3800, Lab. C.) 76 -B1B(REV. 10/81)
Policy 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
tion department. ADDRESS 0;U fQ� e- G
(PRINT OR TYPE ONLY)
Date Applicant LOCALITY -
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSSSST, 11-e rMI;7_5q
COMPENSATION INSURANCE
(This section need not be completed if the work Involved by ABSORPTION UNIT, BTU DTSTRtCT NO. PROCESSED BY
the permit is for one hundred dollars ($100)or less.) 6C
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM r V
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. BOILER, BTU APPROVALS DATE wsPEa is SIGNATURE/
COMPRESSOR, BTU O C) ROUGH
Date � � �/ � Applicant COMPRESSOR,
T APP (CANT: If, aft making this Certificate of VENTILATION SYSTEM FINAL /
Exemption, you should beco a subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATI
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAUVITY O l
LICENSED CONTRACTORS DECLARATION FLOOR BTu V
I hereby affirm that I am licensed under provisions of Chapter 9SUSPENDED UNIT_
WALL
'(commencing with Section 7000) of Division 3 of the Business HEATER:
and Professions Code,and my license is in full force and effect. 1
O
License Number Lic. Class _ D V
K
Contractor Date O
tom exempt under Sec. ;201 25A
Plan check fee �$,. a i• e e 8 .W
8.8P.C .for This reason'
Date: PERMIT ISSUING FEE$ 1 •;• 3,050 Z
Signature TOTAL FEE •e'•,e 305,O 5'
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's LicenseD 0 ZJ '1 8 8
Low for the following reason (Section 7031.5, Business and NAME Jt)Ih e h 5
Professions Code): - ..
IFL�I� I, as owner of the property, or my employees with ADDRESS 6992 4,,-/57/7
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section CITY 'TEL. NO.
7044, Business and Professions Code). OWNER � L 'P cin 5
❑ I, as owner of the property, am exclusively contracting J-04 -
with licensed contractors to construct the project (Sec- MAILn
tion 7044, Business and Professions Code). ADDRESS ., y a )(,y rTo�
CONSTRUCTION LENDING AGENCY CITY San CJG T/?t ass-86G
I hereby affirm that there is a construction lending agency for D
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 Address
STATE LIC.
I certify that I have read this application and state that the LICENSE 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
Pon the obo -men 'oned property for inspection C put ores. .SEE REVERSE FOR EXPLANATORY LANGUAGE
! /�
Signature of Applicant or Agent Dote '