HomeMy Public PortalAbout6031 CAMELLIA AVE_Mechanical__r
WORKERS' COMPENSA1lON,0KL RATION APPLICATION FOR PERMIT
I hereby affirm that 4 have a certificate of consent to self
Insure, or a certfficate of.Workeri Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certtfied copy thereof (Sec 3800, Lab. C.)
20-0046 DPW 9/Bb ,
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
tlon department_ ADDRESS
. (PRINT OR TYPE ONLY)
Date AppllcantLOCAL" •L� �/T
t•10. I NEAREST
TYPE OF APPUAN6CE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS'
' COMPENSATION INSURANCE CROSS STS'
(This section rmmd.not be eted if the work Involved by ABSORPTION UNIT, BTU DMnZ)CT NO. BY
the permit Is for one hundred dollars (;100) or less.) �'
I certify that In the performance of the work for which this AIR FIAfJDUNG UNrT, CFM v
permit Is Issued, I shall not employ any person In any manner
to as to become sublbct to the Workers'Compensatroh Laws. BOII�� BTU APftta US TE ws�CTORs s+cN�rurtr
COrv1ESSOR, BTU_T`1d o b ��H
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of VENnLAT10N SYSTEM FINAL
Exemption, you -should become subject to the. Workers
Compensation provisions of the Labor Code, you must forth- IEVAPORATjVE COOLER VAL D
with complyy with such provisions or''thls permit shall be deem-
bd revoked. FURNACE FAU GRAVRY nn
LICENSED CC)41, ACTORS DECLARATION FLOOR BTU T
I hereby afflrrn that I am licensed under provisions of Chapter 9TER; SU �
SPEND _UNrr—
(commencing wfth Section 7000)of Division 3 of the Business WALL
and Professions Code,andmy
license Is In full fcrcee and affect.
IL
License Number �/ / �L Ic Class L , 0
.. 1 I /
.Contractor "'"`;r'<a�1�at° O
4 I arr"exempt updpr Sec
Plan,check fee a
B.BP.C_Tfor thW reason
PERMIT ISSUING FEE Z
Signature TOTAL FEE
OWNER-BUILDER DECLAPATIQN RAN CHECY APPUCANT
1 hereby affirm that I am exempt from the Contractor's License ,
Law for the following reason (Section 7031.5, l3uslness and NAME
Professions Code): ? P.00
❑1 I, as owner of the property, or my employees with ADDRESS__ 1 ITERS
wages as their sole compensb ion,will do the work and (1 w1
TEL TAL
-the structure Is not Intended or offered for sale(Section C11Y - - �' TO37 -00
7034, Business and Professions Code) �{�►►+yy/ 7.-7 0r
❑ OWNER. C i�C4i� �f■ULI
I, ps owner of the�roperty, am exclusively contracting
with licensed contractors to construct the proled (Sec- MAILADDRESS d ` /Q } a(]
tion 7044, Business and ProfessionsOode . -
CONSTRUCTION LENDING AGBJ.CY CITY 5� TEl NO.,;,?
I hereby affirm that there Is a construction rending agency for ,y,�y��s�yi { �L
90
the performance of the work for which this permit Is Issued CptRACTOR 7�� , 1AIls�lrJl�l _ L�of
(Sec 3097, Cly. C.).
1
Lender'Y Name ADDRESS
QTYiL /VJ TE. NO. �
Lender's Address
I certify that I have read this appllcatlbn•and state that the ��NO. UQASS
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
/jn.1.nh,e abovo-mentioned property for Inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent bats �s