HomeMy Public PortalAbout4819 CAMELLIA AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION 76A364C
I hereby affirm that I have acertificate of consent to self CE -618(2-80) APPLICATION FOR PERMIT
'insure, ora certifi:ate of Workers'Compensation Insurance,or - HEATINGVENTILATING-AIR CONDITIONING
a certified copy-thereof(Sec.3800,Lab.C.)
PolicyNo.—Company
Certified copy is hereby furnished. _ COUNTY OF LOS ANGELES BUILDING AND SAFETY
'
Certified copy is filed with the county building inspection1
department. FOR APPLICANT TO FILL IN BUILD
Date Applicant (PRINT OR TYPE ONLY)
ADDRESS
CERTIFICATE OF ELOCALITY
EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
COMPENSATION INSURANCE NEAREST (( }
(This section need not be completed If the work involved ABSORPTION UNIT, BTU CROSS ST. �'e17Jt-
by the permit is for one hundred dollars (SI00) or less.) - DISTRICT NO. PROCESS�O By L)
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM v � ` 0
permit is issued,I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws. BOILER, BTU P'-
APPROVALS DATE INSPECTOR'S SIGNATURE W
Date Applicant COMPRESSOR,BTU ROUGH _I y
NOTICE TO APPLICANT: If, after making this.Certificate of FINAL Z
Exemption, ,you should become subject to the Workers' VENTILATION SYSTEM,
Compensation provisions of the Labor Code, you must forth-
with comply with such provisions or this permit shall be EVAPORATIVE COOLER VALIDATION
deemed revoked. FURNACE: FAU— GRAVITY_ -
LICENSERCONTR.ACTORS DECLARATION FLOOR: BTU ,
I hereby affirm that I am licensed under provisions of Chapter HEATER: NDED UNIT
9 (commencing with Section 7000)of Division 3 of the Busi- , WAL
ness and Professions Code, and my license is in fall force and
effect. -
License Number Lie.Class—
Contract
lass -
Contractor Dale
0 1 am exempt from the licensing requirements as I am a
licensed architect or a registered .professional engineer Plan check fee 25%Of above.
P• acting in my professional capacity (Section 7051, Bus-
iness and Professions Code). PERMIT ISSUING FEE$ ems:
L.c.or Reg.No. - Date TOTAL FEE 3
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
ereby affirm that i not exempt from- the Contractor's NAME
Ilse Law for the following reason (Section,7031.5. Busi-
ness and Professions Code): ADDRESS '
El 1, as owner of the property, will do the work and the CITY TEL.NO. '
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 MAIL
(Section 7044, Business and Professions Code). ADDRESS :2 3 2'6.4.11
CONSTRUCTION LENDING AGENCY CITY TEL. NO. efe le • e 8
1 hereby affirm' that there is a construction lending agency ��,� q '
for the performance of the work for which this permit is CONTRACTOR C/t/`- IVeA— 2�e to 2350 -
issued(Sec. 3097,Civ.C.).
Lender's Name - ADDRESS -4863 23.506
Lender's Address CITYTEL NO. v
(/e,, Ve 7i f 59s.Z D 3 r1 '6-82
1 certify that I have read this application and state that the STATE LIC.
above information is correct. I agree to comply with all County LICENSE NO. CLASS
ordinances and State laws regulating Heating. Ventilating and
Air Conditioning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter upon t e ah vz-mzntioned properly for
s ra ur• sesta
Signaa Uore of Permtit+ Date