HomeMy Public PortalAbout5221 CAMELLIA AVE_Mechanical__ Ph WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I herelty affirm that. I have a certificate of consent to self '
Iruure,spr a certificate of Workers' Compensation Insurance, . HEATING - VENTILATING - AIR CONDITIONING
l or a cert led copy thereof (Sec 3800 ab-C.) 76A364C
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Policy .1Cb1/ Company ,o/x
Certified copy Is hereby furnish . COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy Is filed with the county building Inspec- FOR APPLICANT TO FILL IN BUILDING ��
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n department. A SS � � //
Date /r`/I—20 App llca (PRINT OR TYPE ONLY) C�
LOCAUTY
NO. TYPE OF APPL1AfJCF OR EQU I PATENT FIS
77
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST /
COMPENSATION INSURANCE SSS ST. L
(This socHon rwod not be eomplet*d If the work Involved by ABSORPTK�N UNIT, BTU DfMK7 NO. PROCESSED By
the permit is for on*hundrid dollars{$100)or less.)
I certify that In the performance of the work for which this A1R FIAfJDiJtJG UNIT,CFM
permit Is Issued, I shall not employ any person In any manner
so as to become subject to the Workers'Compensation Laws. BOILER, BTU APPROVALS DATE _109 ORS S1GNA ra
Date Applicant , �, BTU ROUGmi-[
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensatlon provisions of the Labor Code, you must forth- EyAPORATWE COOLER VAUDATI
with comply with such provisions or this permit shall be �—
deemed revoked. FURNACE: FAU
LICENSED CONTRACTORS DECLARATION FLOOR BTU 'OU]
I hereby affirm that I am licensed under provisions of Chapter 9 FE1[I�R: SUSPENDED UN17
(commencing with Section 7000) of Division 3 of the Business WALL
and f'rofgaalpns Code,and my license Is In full force and effect.
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License Number , U
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Contractor (p0/JN Date 42— /7_-17 I o o 3 Q 5 0 G
F] cI am exempt under Se . W
Plan check fee • 0 . 30506 IL
y
8.8P.C. for this reason Date: PERMIT ISSUING FEE ; _
121 787
Signature TOTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License ,
Law for the following reason (Section 7031.5, Business and NAME
Professions Code):
❑ 1, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and
the structure Is not Intended or offered for sale(Sectlon CITY NO.
70.4, Business and Professlons Code). OWNER �r /
❑ 1, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professloru Code). ADDRESS ,
CONSTRUCTION LENDING AGENCY C!TY C TEL NO. /
I hereby affirm that there Is a construction lending agency for
the performance of the work for which this permit Is Issued - COFACTOR
(Sec. 3097, CIv. C. �� v�•��
ADDRESS l?.r<
Lender's Name
cn- / TEL NO. f,
Lender's Address
STATELIG
I certify that I have read this application and state that the LKB14SE NO. LASS r e�
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
uporyhe a ve-menti operry for Inspection purposes, SEE REVERSE FOR EXPLANATORY LANGUAGE
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Slgnaturs of Appllcant or Agent Dat. - - - -