HomeMy Public PortalAbout5635 CAMBURY AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR'kRMIT •�
1 hereby affirm that I hove.,a certificate)nf consent to self '
insure, or a.cedificotesnf Alork&s'h.ompgObtion Insurance,. " • ` % -
or a certifiedcopy,thereof(Sec.390q Lab. f..) 7eA364C .HEATING - VENTILATING -.AIR CONDITIONING
Policy N.1936"13 Company x"44-,0 p0046 DPW 9%g8 - - - •
Certified copy is hereby furnished. �o�//�/� 'COUNTY OF LOS ANGELES BUILDING AND SAFETY
r ❑ Certified copy is filed withr the county building inspec- FOR APPLICANT TO FILL IN BUILDING
- non department. - )Q F-
(PRINT OR'TYPE ONLY) ADDRESS
'Date 3 ?1- dApplicant - LOCALITY
NO, TYPE OF APPLIANCE OR EQUIPMENT - FEE -
CERTIFICATE OF EXEMPTION FROM WORKERS' - NEAREST 1 I ve
r, COMPENSATION INSURANCE CROSS ST, /� PJ
(This section need ABSORPTION UNIT, BTU not he completed if the work Involved by PISTRIcr No. PRocEsseP av
the permit is for one hundred,dallbis (5100) or less.) (Jl ,
I certify that,in,the performance of the work for which this AIR HANDLING UNIT, CFM fYl
permit is issued, shall not employ any person in any manner '
so as.to become subject to the Workers Compensation Laws. BOILER, BE ' APPROVALS PATE SPECTORS SIGNATURE
Date Applicant COMPRESSOR: BTUy e ROUGH f
NOTICE TO APPLICANT: If, after making'this Certificate of VENTILATION SYSTEM FINAL
Exemption,- you should become subject to the Workers' - -
Compensotion provisions of the Labor Code, you must forth- EVAPORATIVE COOLER - A
-Cvith comply with'such provisions'or this permit shall be,deem - -
.ed revoked. - FURNACE: - FALL / GRRAVVITY
LICENSED CONTRACTORS DECLARATION FLOOR gTU WOiD73570— •a Dd '
I hereby off irm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED—UNIT— - - -
(commencing with Section 7000)of-Division 3 of the Business `HALL
an)Professions Code;and my license is in full force and effect.
yD �� i'vft�%s £ 7c• r
Ic nse Number 'r Lia Class O a
yy O
,Contractor te- l 2 �' FU _ - ti4i:T.i .. V
..
3301
' C
❑ I am'exempt'under Sec. ' '' - '- .-__ -- - H
• • Plan check fee 1 ITEMS
w'
Br6PIC. for this reason. - /3 D .: -(17TAL _e
PERMIT ISSUING FEE § 5
- Date: - ..
TOTAL FEE
Signature CHECK '5C,LIL
OWNER-BUILDER DECLARATION - - - - - " ^ r
PLAN CHECK APPLICANT . ' GRANGE _. � •011
hereby affirm that)am exempt from the Contractor's License -
Law for.the following reason (Section 7031.5, Business and NAME:
Professions Code):. r ' ,
❑ I, as owner of the property, or my employees.with ADDRESS 't - - - 13000-0001 3.779/91`1
wages as their sole compensation, will do the work and Q��,� 1 �i�lZ%ffG
the structure is not intended or offered for sale(Section CITY -. -. - TEL. NO. ..
7044, Business and Professions Code). OWNER
❑ 1, as owner of the property, am exclusively contracting w'Q t:A:f-7r IV
with,licensed contractors to construct the project (Sec MAIL -
Don 7044, Business and Professions Code). e ADDRESS �O-7 Y-
-CONSTRUCTION
.CONSTRUCTION LENDING AGENCY CITYel(y &r4�
hereby affirm that there is a construction lending agency for D
4he performance of the work for which this permit is issued CONTRACTOR G/� „Jy�f .$-€X!'i�E
(Sec. 3097, Civ. C.). -
ADDRESSi•
Lender's Name _ _ _`� t' 4,9-s7QA1,*r 17Q" _ %l' v rs_.':•:
CITY
Lender's Address
'STATE" q LIC -
Certify chat have read this application and state that the^ LICENSE NO. 2�/ 3 CLASS
above information is correct. I agree to comply with all Coiinty _
ordinances and State laws relicama o building construction,-
and hereb authorize repre ntati as of this County to enter -
upon ifi hove-menti erfy for inspection purposes. 'SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent One - - - - •- ®s