HomeMy Public PortalAbout5821 CAMELLIA AVE_Mechanical__ DE�
WORKERS'�I have
ooto of consent
APPLICATION FOR PERMIT
�,r}_e�t:,ei'�c kfrt that I have d;certificate of consent to self
lr�lure, a cerilfictrte of Workers' Compensation Insurance, HEATING VENTILATING - AIR CONDITIONING
copy thereof (Sec- 3800, Lob. C.) 7M'tb~C
� CE-818(REV. 10/81)
P❑ollcy N Company
Certified copy is hereby fumished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certffled copy Is filed with the county building Inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. PE��,,� y+ (PRINT OR TYONLY) A.11-1Date Applicant r,au+�4g W- LOCALITY �
NO. TYPE OF APPLIANCE OR EQUIPMENT Fff Ale
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST 1"
COMPENSATION INSURANCE CROs ST' ," r
(This section need not be completed N the work Invo#red by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY
the permit Is for one hundred dollop (=100)or less,) �`k
I certify that In the performance of the work for which this AIR HANDLING UNIT, CFM U
permit Is Issued, I shaW not employ any person In any manner
to as to become subject to the Worker'Compensation Laws. IBOILER, BTU APPROVALS DATE 1 41Wars SGNATu
Date Applicant Bill �� 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- EVAPORgTTVE COOLER VALIDATI N
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU A �I
LICENSED CONTRACTORS DECLARATION FLOOR BTU (�
I hereby affirm that I am licensed under provisions of Chapter 9 HEAD: SUSPENDED UNFT
"(commencing with Section 7000) of Division 3 of the Business WALL
and Profeaslons Code,and mylicenseIs In full force and JJeffect. d
License Number / Llc. Gloss 1_ V
�-���� 0
Contractor te G
❑ I am exempt under Sec. us
Plan check fee
B.BP.C_ for this reason 2 9 7 a 5 A 5,
Date: �
PERMIT ISSUING FEE $ # 6,0:0 0 0 8
Signature TOTAL FEE I a 64625
OWNER-BUILDER DECLARATION RAN CHECK APPLIC°,NT
1 hereby cr flrm that I am exempt from the Contractors Llcense , e o o (j (�2 5.�4
Low for the following reason (Section 7031.5, Business and NAME
Professions Code): O a 3l -88
❑ I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and CITY TEL NO
the structure Is not Intended or offered for sale(Section
7044, Business and Professlons Code).
01tiRJ62
❑ I, as owner of the property, am exclusively contracting MAIL
with Ilcensed contractors to construct the project (Sec- ADDRESS
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY QTYTEL NO.
I hereby affirm that there Is a construction lending agency for
the performance of the work for which this permit Is Issued. CONTRACT � "' G� ,
(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name
QTY / TEL.. NO.Z '
Lender's Address �7
STATE OF
I certify that I have read this application and state that the LICENSE NO. 3 3 CLASS
above Informotlon Is correct. I agree to comply with all County
ordlnarces and S relating to building construction,
and here orize repress fives of this County to enter
upo above.meat rty forClnspection pup�p�o�ses. SEE REVERSE FOR EXPLANATORY LANGUAGE
flnoture of Applicant or ent Dote