HomeMy Public PortalAbout5208 CAMELLIA AVE_Mechanical__ WORKER'S COMPE7JSACLARATION 2°°°"°° '°'� APPLICATION FOR PERMIT 'LIME G.REIEN
- I hergby�tArinythet-I have n certfiloateoate pf�i consent to eelf,lnsuke, y ; _ - APPLICATION
a oertHickte of Worker's Compensation Insurance, or.a certified - HEATING -VENTILATING -AIR CONDITIONING
copy thereof(Sec.3800 Lab.G.)'
Pdlcy No. 14i? C.� S ml__F Fu COUKTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV.
❑ Cer ffW copy Is hereby furnkhed.
�] CerttW copy Is fled with the county bulk&Q Inspection FOR APPLICANT TO FILL IN �SS 4-2 L
departmarrL (PRINT OR TYPE ONLY)
LOCALITY
Date /O —�O �ppM1cerrt +i �+sG� NO. TYPE OF APPLw4GE OR Ew"ENT FEE
CI FITIFICATE OF EXBAPTFROM WORKEPH NEAREST
ION
CFI088 ST.
COMPENSATION INSUF(/WCE , UNIT,BCU
(This gectlon need not be compiated M the,work Involved by the MAPS PAGE PNiCEl
permit Is for one hundred dollars({100)or lees.) : AIR HAAixJNG UNTr CFM
ownacr wa A+oo®sao er
I certtfy that In the performance of the work for which this permit
Is Issued, I shall not employ any person•In any manner so as to BCHLHRBTL1 L h�
beoome subject to the Workers'Compenestlon Laws.
COOAPRES9DR,BTU <L1 /I O
APPROVALS a+Ta
Die AppOcarrt VENTILATION SYSTEM .
NOTICE TO APPLICANT: If, after m'aklnd this eertlflcete of ROUGH
Exemption,you should become subject to the Worker'Compensation EVAPORATIVE COOLER FINAL `
provisions of the Labor Code, you must,forthwith comply with such
provisions or this p-ermlt @hall be deemed revoked. FURNACE: FAU VITY
LICENSED CONTRACTORS DECLARATION FLOOR BILI G L D VALIDATION ..
I hereby affirm that I em licensed under provlslorls of Chapter P HEAT
(commencing with Sectlon 7000) of Dtvlslon 3 of the Business and
WALL
Profee#lone Code, and my license Is In full force and sffeoL y
�jLloenae N iaAber 70 0 9 Llo ass. z o
Corttracfor s� *P to 8
I am exempt under Soo-
B.
eo- Plan check fee
ILII B.aP.C.f«mtareason PEF1111T ISSUING FEE;
tl 3Q A
ACCT■
DaeTOFEE 3303.T
L�11174.30 a
signature PLAri CHECK APPUC.01T I ITEMS co
l
OWNER-BUILDER DECLARIO
ATN fr /�'
I hereby affirm that I am exempt from the Contractor's Ucense Law NAME , TOTAL 174-30
for'the following teaeon (Section 7031.6, Business and Professions �n
Coda): X88 (EC 174.30
❑ I, as owner o1 the property, or my employees with wages
as their sole compensation, will do the work and the CfTy TEL NO, .00
l flf7lL
structure Is not Intended or offered for sale (Sect)on 7044, '
Business and Professions Code). OW?CR M ?+�l� o oL
❑ I, as owner of the property, am exclusively contracting MAIL L.R.R.RJ1JLMi +7�' 18/96
with licensed contractors to construct the project (Sec- ApOgE88 — L A70W 5367 1 M12:46
tion 7044, Business and Profeeslona Code).
NOf
CONSTRUCTION LENDING AGENCY 011-Y -r- UTV
TEL
Ihereby afflrm that there le a construction lending agency for ,
the performance of the work for which this permit le Issued CONTRACTOR
(Seo.3097,Civ.C.).
ADDRESS Z
LendWa Name
CITY TEL N>
LerKWs Address SLATE LIC.
I certify that I have read this application and state that the above LICENSE NO. CLASS —Z�
Information is coirecf. I agree to comply with a1f County ordlnanoes
and State laws relating to burldfiQ conatr'uction,and hereby audxxtm
representatives of this County to enter upon the above-mentioned
property for Inspection purposes. SEE REVERSE FOR EMANATORY LANGUAGE
i
ft3%fn_X-E OF APPLQW OA DATE
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