HomeMy Public PortalAbout6029 CAMELLIA AVE_Mechanical__ WORKERS' COMPENSATION DECIARATI ON APPLICATION FOR P E RM I T
I hereby afflrm that t have a certlflcate of consent to self
Insure, or a certificate of Workers Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certlfled copy thereof (Sec 3800, Lab. C.) 7636C
240646 DPW 9/86
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
t10de mens. ADDRESS
(PRINT OR TYPE ONLY)
�j LOCAUTY �jvJ C
Date Applicant NO. TYPE OF A?PUA}CE OR EQUIPMENT FEE 7 �7
CERTIFICATE OF D(EMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST. y
(This 4eciion need not be corn toted If the.irorklmrohred by
ABSORPTION UNIT, BTU DtSTRtCT NO. Y
thpt permit Is fbr one hundred dollop ($100) or lets.) �r n
I,certlffyy that In the performance of the work for which this AIR HANDLING UNIT, CFM v
perm ltli Issued, 1.shall not employ any person In any manner
so as to become subled to the Workers' Compensation Laws. BOILER, BTU APPROVALSAPPROVA� DAT! NWECTOR•3 SIGNATURE
SS
OOMPREOR, BTU Y .Z67,-0. ROUGH
Date , Applicant
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 COOISt
with compsy wkh such provisions or this permit shall be deem
ed revbked. / RJRNACE: FAU GRAVITY
UCEND CONTRACTORS DECLARATION ROOK BTU
SE
I hereby affirm that I am licensed under'provislors of Chapter 9 HEATER: Sl1SPENDED UNIT—
(comrimencing with Sedlon 7000)of Division 3 of the Business WALL
and Profeulors Code,and my I Icense Is In full force and effect.
License Number4c. Class— — , O
U
i Contractor
❑ I amexempt under Sec.
Plan check fee W
B.BP.C. for this reason PERMIT ISSUING FEE $ n.
Data.: �
TOTAL FEE �D
Slgnature
OWNER-BUILDER DECLARATION PLAN CrrFac APPUCANT
I hereby afflrm that I am exempt from the Conft- dors License ,
Law for the following reason (Sectlon 7031.5, Business and NAME- {
Profeulons Code): S _...
❑ I, as owner of the property, or my employees with ADDRESS �T�A
es 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) OWNER
❑ OWNER _
I, as owner of the property, am exclusively contracting 1 ITQiS
with licensed contractors to construct the project (Sec-
tion 7044, Business and Professiors Code 7� TOTAL 37-00
CONSTRUCTION LENDING QTY a TEL NO.04�>7 v u , UECK -67.001 hereby affirm that there Is a construction lending agency for
the performance of the work for which this permit Is Issued CONTRACTOR
(Sec 3097, Clv. C_).
ADDRESS
Lenders Name
CITY TEL NO. 1JMG—OWI 1/26/90
Lender's Address 57 1 AM $x.32
1 certify that I have read this appllcation and state that the ��NO U�
above Information is corred. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
upon the above-mentloned property for Inspection purposes. TEE REVERSE FOR EXPLANATORY LANGUAGE
j Signature of Applicant or Agent