HomeMy Public PortalAbout6027 CAMELLIA AVE_Mechanical__ "'°rte O°"' "°" DECLARATION
APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self
Insure, or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
9r a certlffed copy thereof (Sx 3800, Lab. C.) 76364C '
240046 DPW 9/88
Pollcy No. Company
❑ Certlfled 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
tion department.
(PRINT OR TYPE ONLY) ADDS
Data 1 Applicant T� -`- 1- LOCAUTY
NO. TYPE OF APPUANCE OR EQUIPMENT FEE L a c�T
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE �ST• U S
(This section need not be eom If the work Involved by
ABSORPTION UNIT, BTU DtSTRJCT NO. , Ina
the permit is for ono hundreddollars (=100) or Less.) AIR
n(1/r(/
I certify that In the performance of the work for which this AIR HANDLING UNIT, CFM J V
permit Is.lasued, I shall not pmploy any person In any manner
to as to become subject to the Workers Compensation Laws. �� BTU APPROVALS DATE INSPECTOR'S SIGNATURE
COMPRESSOR, BTU 7`02 D b• ROUGH
Date Applicant
NOTICE TO APPLICANT: If, after making this Certfflcate of VE1,MLATION SYSTEM FINAL
Exemption, you should become subject. to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLERV�
with compI with such provisions or this permlt shall be deem-
ed revoked. . FURNACE: FAU GRAVITY 1 O(�
LICENSED CONTRACTORS 0 V DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provlsloru of Chapter 9 HEATER: SUSPENDED UNIT—
(commencing with Section 7000)of Division 3 of'the Business WALL
Md Professions Co",and my license Is In full force and effect.
CL
License Number YpXa 2 I C. Class C-°Z d , O
u
Contract '" Bete
O
❑ 1 a n exempt under Sec. rj
Plan check fee LU
B.BP.0 for this reason CL
PERMIT ISSUING FEE $ d w
Date: Z
T
Signature OTAL FEE
OWNER,BUILDER DECLARATION RAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractors License
L.a �.00
w for the following reason (Section 7031.5, Business and NAME'
Professions Code):
❑ I, as owner of the property, or my employees with ADDRESS 1 ITN
wages as their sole compensation,will do the work and
the structure Is not Intended or offered for sale(Section CITY TEL NO. TOTAL 37 -00
7044, Business and Professions Code). OWNER / CWC/, 37.(XI
❑ I, as owner of the property, am excluslvely.contractlnp
with licensed contractors to construct the project (Sec- �/O �O6 _ ,00
tion 7044, Business and Professions Code). O
CONSTRUCTION LENDING AGf3JCY CITY b TELNO. a
I hereby affirm that there Is a construction lending agency for - u
the performance of the work for which this permit Is Issued TRACTOR7�� , 1 1/26/?I
(Sec. 3097, 0V. C> uti 1 AM 8:32
Lenders Name ADDRESS - L
CITY 4176TEL NO. d
Lenders Address
I cert) that I have read this application and state that the STATE UC
certify PP UCENSE NO. �6 (]ASS (moo[ O
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
uT , th above-mentioned property for Inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
li'tit� I �
Signature of Applicant or AQertt Date