HomeMy Public PortalAbout6025 CAMELLIA AVE_Mechanical__ WORKERS' `°".PENSA ION D`�A1ON APPLICATION FOR PERMIT
I hereby pfflrm that I have a certificate of consent to self
Insure, or a certificate of Workeri tompensatlon Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec. 3800, Lab. C.) 76A'i64C
20-0646 DPW 9/88
Policy No Company
❑ Certified copy Is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the county building Inspec- FOR APPLICANT TO FILL IN BUILDING B
tion apartment. ADDRESS
'(PRINT OR TYPE ONLY)
Date Applicants= Lor.�LITY G?
No. TYPE of APPUANCF OR EQUIPAtiENT FEE
CERTIFICATE OF EXENt MC)N FROM WORKERS' I NEAREST
COMPENSATION INSURANCE CROSS ST' V�
(This sectilon need not be completed if the work Imrolved by ABSORPTION UNIT, BTU DrsTutcr NO. PRCCMW BY
the PWMH Is for one hundred dollars (;100) or lass.)
I certify that In'the performance of the work for which this ATR HANDLING UNIT, CFM v
permn Is Issued, I shall not employ arty n In any manner
so as to become subleEt to the Workers m pensation Laws. BOIIJ R BTU l,, APPROVALS DATE s+cwrure
/ BTU 7^�t JD RCOGH
Date Applicant
NOTICE TO APPLJCANT: 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
with compI with such provisions or this permit shall be deem-
ed revoketl. / FURNACE. FAU GRAVITY ROD
UCENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed uFlder provisions of Chapter 9 HEAD SUSPENDED UNIT-
(commencing with Section 7000)of DlvIsIon 3 of the Business WALL
and Professions Code,.and my license Is In full force and effect.
CL
Ucense Number��, J Lic Class « D , U
Contractor 4
❑ I am exempt under Sec. 0
Plan check fee w
B.BP.C. for this ceawn d
PERMIT ISSUING FEE $
Date: Z
TOTAL FEE
Signature
OWNER-BUILDER DECLARATION RAN CHECK APPLCANT
I hereby affirm that I am exempt from the Contractors License oilLaw for the following reason (Section 7031.5, Business and NAME
Professions Code):
ADDRESS
❑ I, as owner of the property, or my employees with ANT,
wages as their sole compensation,will do the work and y-�
the structure is not Intended or offered for sale(Section CITY �' ,�-;kr017 57.011
7044, Business and Professions Code). OWNER 1 11C�F�
❑ I, as owner of the property, am exclusively contracting
with licensed contractor to construct the project (Sec- "'0 4!� TOTAL 3 -01D
tion 7044, Buslness and Professions Code}
CONSTRUCTION LENDING AGENCY aTY TEL NO. �ev MCK 67■00
1 hereby affirm that there Is a construction lending agency for �y.��� Athe performance of the work for which this peweir-
rmit Is Issued CONTRACTOR , , E
(Sec. 3097, Civ. C_).
Lender's Name '7
c'T'.S . TEL No. 6 00170-0401 1/6/90
Lender's Address x`.49 1 All $:3
I certify that I have read this application and state that the NO s� UC ASS 4^ o
above Information Is correct. I agree to comply with all County
ordinances and State laws relating to bullding construction,
and hereby authorize representatives of this County to enter
upon The above mentionarty for Inspection purpcsea.
_ SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent