HomeMy Public PortalAbout5957 CAMELLIA AVE_Mechanical__ ff RS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
`I herq,�d+Qffk,*rTr that I have a certificate of consent to self ,
Insuce, or o'certtflcate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certffil PY thereof
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. .Foil cy No mpany COUNTY OF LOS ANGELES BUILDING AND SAFETY C� s
Certified copy Is hereby furnished.. 1�1
,15
Certtficc
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Is filed with the county building Inspec- FOR APPLICANT TO FILL IN BUILDING
(PRINT OR TYPE ONLY)DaiApplicant LOCAl1fY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPT FROM S' NEAT
COMPENSATION INSURANCE CROSS ST.
(This section nMd not be comp6tod If the work Involved by ABSORPTION UNIT, BTU
the pernmB Is for one hundred dollars (;100)or less.) �` V�(
I certify that In the performance of the work for which this AIR HANDLING UNIT, CFM lJ
permit is Issued, I shall not employ any person In any manner'
to as to become subject to the Workers'-Compensation Laws. BOILER,-BTU APPROVALS DATE ars TUBE
COMPRESSOR, BTU -� �fO 7C] ROUGH I
Date ATx,llcant
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 OOOLER VALIDAT N
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: F,AU GRAVITY
LICENSED CONTRACTORS DECLARATION FLS BTU
I hereby affirm that I am IIcor4ad under provisions of Chapter 9 HEATER: SUSPENDED UNIT
'(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code,and my license is In full force ark Off.
O
Llce umber Class , V
GC
C to 1 9 al7lAl C
❑ I exempt u er Sec. sss
Plan check fee #.o o o'o 0,8. L
B.&P.C. for this reason Date PERMIT ISSUING FEE; lI o - 20,5-0 Z
Signature TOTAL FEE_
,
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT o o - 2(1506
I hereby affirm that I am'exempt from the Contractor's License oil.Law for the following reason (Section 7031.5, Business and NAME 0 5 0 6�-,8 5
Professions Code):
❑ I, as owner of the property, or my employees with ADDRE-�S
wages as their sole compensation,will do the work and
the structure Is not Intended or offered for sale'(Section CITY TEL �'
7044, Business and Professions Code).
O'WN
❑ I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TEL NO,
I hereby affirm that there Is a construction lending agency for
the performance of the work for,which this permit Is Issued OOWRAC-T
(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name
C1TY TEL NO. � .�
Lender's Address ATE ' / �j('
I certify that I have read this application and state that the LICENSE NO. - 'tel !J CLASS.
above Inforrratlon Is correct. I agree to comply with all County
ordinances and State lows relafing to building construction,
a reby authorize representatLves of this my To enter
u on entioned property for In ��urposes_ SEE REVERSE FOR EXPLANATORY LANGUAGE
ro of App II ..Agent