HomeMy Public PortalAbout5328 CAMELLIA AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
a 4e{rby�yff f}wt'I hb4a d'certiflcate of consent to self
3*isure',ol:_at•Etl{Icate of Workers' Compensation Insurance, HEATING - VENTILATING - .Alk CONDITIONING
! «a Xlfl copy thereof (Sec.'3BC0, Lab. C.) 76A364C
CE-818(REV. LO/81)
Policy❑ N rt Company
Certified copy Is heroby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
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❑ Certified copy Is flied with the county bulldlnp Inipec-. FOR APPLICANT TO FILL IN BUILDiNG 2� �1�1t!LU/J �v
floe d rtmet
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ep° (PRINT QR TYPE��tJLY) ADDRESS
Date Applicant LOCAL"fY
NO, TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE CROSS ST•
(This section he"not be completed If the work Irrvolved by ABSORPTION UNIT„BTU DiMK7 NO. BY
tio
the permit Isfor one hundred doltars (;100)or.leu.) AIR HANDLING UNIT,CFM y
I certify that In the performance of the work for which �O
permit rs Issued, I shall not employ any n ma
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to as to become s(u�jblect to the W n BOILER, BTU APPROVALS 'ATIORS SpNATU RI
DaTes���'�d APPII t COMPRESSOR, BTU ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of The Labor Code; you must forth- EVAPORATIVE COOLER- VALIDA- ON
with 'comply with such provisloht or this permit shall be
deemed revoked. FURNACE: FAU
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed undet provisions of Chgpter 9 SUSPENDED UNIT
'(commencing with Section 7000) of Dlvrslon 3 of the Buslr>ass HEATER. WALL
and Professions Code,and my license is In full force and effect.
04o d O
License Number Alc. Class V
Confroctor Date 19 7 4,5'A 0
❑ I ism exempt under Seca LU
Plan check fee #-o,o. •,v e 8 , a
B.BP.C. f«this reason PERMIT ISSUING FEE ; I 's,o 4 a 0 0 �
Signature
Date:
TOTAL FEE
- ,
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm thtrt I am exgm'pt from the Contract«'s License ,
Law foe the following region (Sectlon 7031.5, Business.and NAME 1 -88
Professions Code).
❑ I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the W«k and CITY TEL NO
the structure Is not Intended oe offered for sale(Section
7044, Business and Professions Code).-
OWNER
❑ I, as owner of the property, am exclusively contracting
with llcensed contractors to construct the project (Sec- ADDRESS
3 ��
tlon 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there Is a construction lending agency for ' T
TEL-
the performance of the work for which this permll Is Issued CONTRACTOR
(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name
CITY TEL NO.
Lenders Address
STATEUC
I certify that I have read this application and state that the LICENSE NO. CLASS
above Information Is correct. I ogees to comply with all County
ordinances and State Itrws rolatl to building construction,
and'hweb t riz rep
it
es of this County to enter
th a v o p for Inspedlon purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
AA L
`QCT
Signature of Applicant - Qe
Anr Dole ,. .