HomeMy Public PortalAbout6033 CAMELLIA AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby afflrm that 1 have a certificate of consent to self '
Insure, or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
Of a certified copy tFreieof (Sec 3800, Lab. C.) 7&A-
20U DPW 9/9B
Policy No. Company
❑ Certified copy Is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy Is filed wlth'the county building Inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. 63
(PRINT OR TYPE ONLY)
Date-1 ApplicantW"Llr �� LOCALITY 7�� �'t—d/T G
NO. TYPE OF APPUAtJ(F OR EQUIPMEM FIE
CERTIFICATE OF EXEMPTION FROM WORKERS'
NEAREST
COMPENSATION INSURANCE �ST. 761
{Thls section need not�&completed tf the work Imrolved by ABSORPTION UNIT, BTU MTR gY
the permit Is for one hundred dollars ($100) or leas.)
I certify tha} In the per(orm4nce of the work for which this AIR HANDLING UNIT, CFM
�U /T7'
perinit Is.Isiued;I shall riot employ any person'In arty manner
so as to'become subject to the Worker'Compensation Laws. BOILER BTU Arauavus IPATE INSPECTOVS SrNATLW
.COMPRESSOR, BTU ' V ROUGH
Date Applicant
NOTICE Tb APPLICANT: If,. after making this Certlflcate of VENTILATION SYSTEM FINAL
Exemption,' you should become subject to the Workers
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER L A
with compI with such provisions or this permlt ih,all be deem-
e� revoked.-. 1 F RN CF: FAU B� GRAVITY
LICENSED CONTRACTORS DECIARATIOf�
•1 hereby affirm that I am licensed under provisions of Chapter 9 HEATER. SUSPENDED—UNIT—
(commencing with Section 7000}of Division 3 of the Business WALL
and Profesilonz Code,and my license Is In full force and effect.
CL
Ucense)slumber' 3 Ic. Class' C 6 O
- U
Contracto
Contractor nate P CIO
❑• I aPn exempt under Sec. rj
Plan check fee a
B.BP.0 for this reason PERMIT ISSUING FEE $
Tk,te: Z
TOTAL FEE
Signature
OWNER-BUILDER DECLARATION fLkN C�APPLICANT
I hereby affirm that I am exempt from the Contractors License ,
Law for the foHowing reason (Sectlon 7031.5, Business and NAME
Professions Code): i...
❑ I, as owner of the property, or my employees with ADDRESS,
i
wages as their sole compensation,will do the work and . L
the structure Is not Intended or offered for sale(Section -TY TFL �' 3307 77.1(1
7t", Business and Profeulons Code}. OWNER
I, as owner of the property, am exclustVely contracting �'
❑ G� 1 ITEM
with licensed contractor to constryct the project (Sec- TOTAL ��
tion 7044, Business and Professions Code). . .
CONSTRUCTION LENDING AGENCY CITY O.f TEL NO. a,PF"6 {gyp; 37.00
I hereby affirm that there Ic a construction lending agency for
the performance of the work for which this permit is Issued CONTRACTOR T
(Sec 3097, Civ. C-).
Lenders Name ADDRESS yyy0_ � r L p�
CITY TEL NO. IrJW—LR1U1 1J0�7U
Lender's Address STATE UG 1 AM $m.,s1
1 certify that I have read this application and state that the LCEN E NO j 640
above Information Is correct. I agree to c9mply with all County
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
);the abov&mentloned property for Inspection purposes. _
SEE REVERSE FOR EXPLANATORY LANGUAGE
Slprwtvra of Applicant or Apart Date (MIs