HomeMy Public PortalAbout4935 CAMELLIA AVE_Mechanical__ A WQRKER'SCOMPENSATION DECLARATION 76A364C 89 APPLICATION FOR PERMIT .�� � ..����� -
I heP¢,b�y aFfi,rm IhaLI have a�cerlificate of consent to self insure,
or a c�,.rtificate
opy thb of Worker's Compensation Insurance, or a certifiedHEATING-VENTILATING - AIR CONDITIONING
c ;`(Sac.3800 Lab.C.) Q�
Policy No:73A9�Company�1rf/ICYI COUNTY OF LOS ANGELES -DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
Certified copy is hereby furnished.
Certified copy is filed with the county building inspection FOR APPLICANT TO FILL IN BUDDING
department.
,f ` (PRINT OR TYPE ONLY)
Dale/C�Applicanl L�-T LOCALITY
N0. TYPE OF APPLIANCE OR EQUIPMENT ,FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
..
CROSS
COMPENSATION INSURANCE • ,
ABSORPTION UNIT,BTU ASSESSOR
M
perms section isfor
need not be completed the work involved by the MAP BOOK PAG PARCELy
permit is forr one hundred dollars($100)or less.) AIR HANDLING UNIT,CFM
9
1 certify that in the performance of the work for,which this permit DISTRICT NO. PROCESSED y
is issued, shall not employ any person in any manner so as to BOILER,BTU Q C
becomsue subject to the Workers' Compensation Laws. tfQ
COMPRESSOR,BTU
APPROVALS DATE INSPECTORS SIGNATURE
Dale Applicant VENTILATION SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of ROUGH
Exemption,you should become subject to the Workers'Compensation EVAPORATIVE COOLER FINAL t -t
provisions of the Labor Code, you must forthwith comply with such -1 —
•provisions or this permit shall be deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU VALIDATION
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT_
(commencing with Section 7000) of Division 3 of the Business and HEATER: WALL -'
.Professions Code,•and my license is in full force and effect.
License Number �- Lic.Class
Contractor Date O
❑ am exempt under Sec. Plan Check fee f..)
Cr
B.BP.C.for this reason ` PERMIT ISSUING FEE $ bO t;:_. 0
Date: TOTAL FEE WW
Signature - '
'OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT - Fn
Z
I hereby affirm than am exempt from the Contractor's License Law NAME
for the following reason (Section 7031.5, Business and Professions
y .'
Code): - ADDRESS ACCT..Y
(, as owner of the property, or my employees with wages �ti(J7 37.J-1,
as their sale compensation, will do the work and the CITY TEL.NO. ,
structure is not intended or offered for sale (Section 7044, -
Business and Professions Code). OWNER n 1 l t ENS
❑ - I, as owner of the property, am exclusively contracting MAIL IGITA� - _37 — LTL_
with licensed contractors to construct the project (Sec- ADDRESS 77
tion 7044, Business and Professions Code). -
__
CONSTRUCTION LENDING AGENCY CITY TEL.NO. CHHN(3t
hereby affirm that there is a construction lending agency for CONTRACTOR D
the performance of the work for which this permit Is issued
(Seo.3097, Civ, C.). r _ i
ADDRESS illJl llu IIL)I�1. hi i/'i
Lender's Name - J /.SGv .1 ri Y
CITY TEL.NO.�9 6 _y
Lender's Address STATE LIC. LC/ - '
certify that have read this application and state that the above LICENSE NO. CLASS
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 the above-mentioned '
prtyYslFtectiop-pupes. -- / �- SEE REVERSE FOR EXPLANATORY LANGUAGE
51riaruni OF APPLIG A