HomeMy Public PortalAbout6035 CAMELLIA AVE_Mechanical__ hereby affirm WORKERS' I Ina q`I cWIfL"@ of o�nt to self APPLICATION FOR PERMIT
Insure, or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING AIR CONDITIONING
or a certified copy thefeof (Sec.`�800, Lqb, C.) 20-004C
240646 DPW 9/88 '
Policy No Company
led copy I hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
F-1 Cert
Certified copy Is filed with the county building Inspec- FOR APPLICANT TO FILL IN BUfLDING
tion department; (PRINT TYPE ADDS G
Date D Applicant LOCAL." G`T
0. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EMFIION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST. /lam
(This secilon read not be completed If the work Inroh-ed by ABSORPTION UNIT, BTU DM7RK7r NO. � BY
the permH Is for o" hundred dollars ($100) or lass.) i✓
I certify that In the performance of the work for which this AIR HANDLING UNIT, CFM
173#�
peimlt Is Issued, I shall not employ,any person In any manner
BOILER, BTU APPROV,� DA 51C,w,rUftf
so as to biome subject to thew Workers Comperisatlon Laws.
Dart e COA PRESSOR, BTU ROUGH
Applicant
N( TMCE TO APPLICANT: If�f
after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, .you should ecome subject to the Workers'
C6mpensatlon provisions the labor Code, you must forth- EVAPORATIVE COOLER VALI
with compI wlth'such provisions or this permitshall be deem-
, ad revoked. FURNACE: FAU V GRAVITY
" LICENSED CONTRACTORS DECLARATION. FLOOR BTU
I hereby affirm that I am licensed under provislors of Chapter 9. HEATER: SUSPENDED UNIT—
(commencing'with$action 7000)of'Division 3 of the Business WALL
and Professions Code;and-my license Is In full force and effect.
CL
License Number��2 I Ic. Class �Z 0 PooO
U
Confracto G 1e V ad
❑ 1 am exempt under Sec. G
Plan check fee Lu
B:BP.0 for this reason I a
PERMIT ISSUING FEE #
Date: Z
TOTAL FEE
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractors License ,
Law for the following reason (Section 7031.5, Business and NAME i
Professions Code): 2
❑ I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and TEL
the structure Is not Intended or offered for sale(Section M TEL �'
7044, Business and Professions Code} OWNER G� CFY3307 '�
❑ I, as owner of the property, am exclusively contracting MAIL 1 IT[.i 1j
with licensed contractors to construct the project (Sec- �6 l / 6 TOTAL. 37-00
tion 70", Business and Profasalons Code).
CONSMC110N LENDING AGEN crry ��M TEL NO.DjpO f(f u 37.00
I hereby a+Flrm that there Is a construction lending agency fpr'
the performance of the work for which this permit Is Issued CONTRACT04ZCIMISE .00
(Sac. 3097, Civ, C,}
ADDRESS
Lender's Name
r
aTY . C y�,f TEL NO. �Z L 00ID --DDD 1 11/26/90
Lender's Address STATE UC uLt't 1 Ali 8:31
1 certify that I have read this application and statemthat the LICENSE NO �() 3 CLASS G..Z
above Inforatlon Is correct. I agree to comply with all County _
ordinances and State laws relating to bullding construction,
and hereby authorize representatives of this County to enter
upon the above-mentloned property for Inspection purposes.
SEE REVERSE FOR EXPLANATOCiCY LAN4GU/1GE
Signature of Applkant or Agent Dat, tet