HomeMy Public PortalAbout6030 CAMELLIA AVE_Mechanical__ WQRt�ScoMPENSATiON°EC` `"''°" 7&k)WP'"°'8° APPLICATION FOR PERMIT DIME GREEN,
I hereby efflFm Mat.1 have a cortifloate of oonsent to self Insure,
or 1 oertWoate of Worker's Compensaflon Insurance, or a oerttfled HEATING -VENTILATING-AIR CONDITIONING
copy thereof LabrJ
t�OGpB`J
Polley NoLr COUNTY OF LOS ANGELES' DEPT OF PUBLIC WORKS ILDING AND SAFETY DIV.
❑ CerMW copy is hereby funnWood.
Calmed ocpy in flied with the cotmly budding Inepectfon FOR APPLICANT TO FILL IN AOR N h0,740 6 AMQL L(a A ,-,
PRINT OR TYPE ONLY)
Dale "� C- S fl-1 S A^-�T l LOCALrrY T• �--
No. TYPE OF APPLIANCE OR EQUIP11ENf FEENEAREST
EF
CMFICATE OF EXEMPT10WORKERS'N FROM WORS' C �V'S 7'0 AfA S
COMPENSATION INSURANCE ABSO PT"UNIT BTU
o
(ThIa section need not be ompleted K the work Involved by the PAGE PARCH-
permtt Is for one hundred dollar(=100)or leas.) AIR HANDLING UNIT CFM m
oecr rro, Pnocaeo®BY
I.Oertify that In the performance of the work for which this permit
Is Issued, I shall not employ any person In any manner so as to BTU
become subject to the Workers'Compensation Laws. D� O -15
BTU
APPMOVAu an seP�rnrre siewAru�s
Data Applloaru VENTILATEON SYSTEM
NOTICE TO APPLICANT: If, after making this Certificate of HOUGH
Exemption,you should become aub)ect to the Workers'Compensation EVAPORATIVE COOLES=T FW
AL of the Labor Code, you must forthwith comply with such
provtslons or this permk shall be deemed revoked. FURNACE FAU G �— S VALIDATION
LICENSED CONTRACTORS IO
ACTORS DECLARATN FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATS SUSPENDED UNIT
(commencing with Section 7000) of Dlvlslon 3 of the Business and WAS
Professions Code, and my Ibsnse is In ful(force and effect ,t�L` �
Lkenee Number Lb.Goes
d
Contractor K C-
8F-1I am exempt.under Seo. D1ds Plan Check fee Cr
B.BP.C.for this reason PERMIT ISSUING FEE; !�! 0
Deis: TOTAL FEE d
So-b-rre PLAN U)
OWNE P,BUILDER DECLARATION CJS(APPLIGAINT Z
I hereby affirm that I am exempt from the Contractor's License Law NAIVE ^if
for the following reason (Section 7031.6, Business and Profeawons
Coda): ADDRESS /2S^E, 4Ao-r74 Ce-A124 <T,O
❑ I, as ornmer of the property, or my employees with wages fiXT•r
as their sole compensation, will do the work and the CITY TEZ NO. 6-791-7xq 3+J7 IC6.K'
structure Is not Intended or offered for sale (Section 7044,
Buslnasa and Professions Code). OWNERK R I S L' O A 4 3 o rr!/i 7f✓ 1 ,I I U is
❑ I, as owner of the property, am exclusively contracting �1L
with licensed contractors to construct the project (Seo- MAIL
ALAIL8 gZ edtMos,7�rQ 2/il L �}L`�Q TE►TAL 105
tion 7044, Business end Profesalons Code). CITYTEL NO. DECK
1051 T2'
CONSTRUCTION LENDING AGENCY g �' 6—��`�&
I hereby affirm that there Is a construction lending agency for
the performance
of the work for which this permit s Issued
(Seo.3097, Civ.C.).
ADDRESS
tenders Name
aTY A- TB—No. 4/15/52
Landers Address STATE / tx. m 2919 1 AM °:�'4
I certify that I have road thla application and state that the above LICENSE NO. 63 7O 7 ansa C Z—
Inform0w Is ..I agree to compty with all County ordlnancee
end State roMng tc ulkihtg oDnatructkm,and hereby authortze
rep t my to enter upon the endorsed
prope s SEE REVERSE FOR DtP11- ATORY L.ANOUACkE
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