HomeMy Public PortalAbout5419 CAMBURY AVE_Mechanical__ DEC
TION
WORKERS'
t'l 4ov a certificate
cafe of consent
APPLICATION
PP IC p TION FOR PERMIT v
I E`_
affiTrn shot'I have a certificate of consent to self PY IL P9 Y\7 P(!NE i
ihs p certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR- CONDITIONING
or d certified copy thereof (Sec. 3800, Lab. C.) 76A364C
CE-818(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 inspea- FOR APPLICANT TO FILL IN BUILDING p r nG
tion department. _ - (PRINT OR TYPE ONLY) ADDRESS / ,L
Date "Applicant. LOCALITY c C
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE �,�,�. iftIi0 CROSS ST.
(This section need not be completed if thin work Involved by ABSORPTION UNIT, BTU y(/ sc ser=s ' DISTRICT NO, PROCESSED BY
the permit is for one hundred dollars ($100)or less.)
AIR HANDLING UNIT,CFM y S T
I certify that in the performance of the work for which this 999
permit is issued, I shall not employ any person in any manner BOILER, BTU
so as to become subject to the Workers'Compensation Laws. APPROVALS DATE INBPE RIGNATUR
Dote Applicant COMPRESSOR, BTU ✓ VD ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of theI Loboc Code, you must forth- EVAPORATIVE COOLER - VVA!L16WJT16N )oY
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU.S�_GRAVITY D
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED�_UNIT_
'(commencing with Section 7000) of Division 3 of the Business - WALL - -
and Professions Code,and my license is in full force and effect. d
O
License Number Lic Class D V
c' U 09
Contractor Date ;2 8 2 a 4.A 0,
F1I am exempt under Sec. # e e e o)e 8 d
Plan check fee
B.BP.C. for this reason' - N
Date: PERMIT ISSUING FEE $ 1 • - 44,50 Z
Signature TOTAL FEE S e s e 44.500
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
1 hereby affirm that I am exempt from the Contractor's License - D 1 'l 0 4 8 7
Law for the following reason (Section 7031.5, Business and NAME ��- L.-, �•t
Professions Code): -
I, as owner of the property, or my employees with ADDRESS n7 I L 41. C_VNIMbu
wages as their sole compensation,will do the work and -�•
the structure is not intended CITY 'l-e or offered fonsa le(Section V"l TEL. NO.2$1- 6
7044, Business and Professions Code).
❑ OWNER / IJ- I,i L r
I, as owner of the property, am exclusively contracting IR
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS
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 D
(Sec. 3097, Civ. C.).
- ADDRESS
Lender's Name
CITY TEL. NO.
Lender's Address - - -
,
I certify that STATE LIC.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
upon Ih - Bove-mentioned property for inspection purposes. .SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicom or Agent I Date - --