HomeMy Public PortalAbout6042 CAMELLIA AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION
hereby affirm that I have a certificate of consent to self APPLICATION FOR PERMIT
Insure, or q certificate of Workers Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certlfled copy thereof (Sec 3800, Lab. C.) 764364E
2D-0046 DPW 9/98
PoHcy 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 O{2 TYPE ONLY)
Date Applicant
NO. LOCALI TI
O. TYPE OF APPLIANCE OR EQUIPMErIi FEE
CERTIFICATE OF DTAVTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
(This section read not be comp leted M the work lnvofwd by ABSORPTION UNIT, BTU NO. rY/ BY
the psrmft Is for one hundred dollar (;100) or lass.) AIR-IAANDUNG UNIT, CFM .5 , o
I certify 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 become subject to the Worker'Compensation Laws. BOILER, BTU f� AP?Rpr,L DATE rISPEiTORS SxatJ TL*r-
Date Applicant COMPRESSOR, BTU V ROUG4
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM F9 NAL
Examptron, you should.become subject to The Workers
Compensation provisions of the Labor Code, you.must forth- EVAPORIVE AT03OLER VALI ATION
with tomply with such provisions or this permit shall be deem-
ed revoked. RJRNACE: FAU GRAVITY I
LICENSED CQNTRACTORS DECLARATION FLOOR BTU
1-hereby affirm that I am licensed ur4er provIslorm of Chapter 9 HEATER: 'SUSPENDED UNIT
(commencing with Sectlob 7000)of Division 3 of the Business W1
and Professions Code,and my license Is In full force and effect.
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' a
License Number I Ic. Clapi , O
/ u
Contractor Date 0
❑ I am exempt under Sec. rj
Plan check fee
B.&P.0 for this reason d
PERMIT ISSUING FEE $ Z
fie: _
TOTAL FEE 14 L2 0
Signature
OWNER-BUILDER DECLARATION RAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractors License ► _ _ ____ _ .. .
Law for the following reason.(Section 7031.5, Business and NAME it
Professlons Code): w
I, as owner of the property, or my employees with ADDRESS - 1
_
wages as their sole compensation,will do the work and ANT,
the structure Is not Intended or offered for sold(Sectlon Com• JE' NO. M7 Q.00
704 Business and Professions Code}. OWNER
I, as owner of the property, am exclusively contracting —. 1 ITQtS
with licensed contractors to construct the project (Sec- SILRESS 110k. , TOTAL ��
tlon 7044, Buslness and Professions Code).
CONSTRUCTION LENDING AGENCY OTY •• TEL. NO. GE�
I hereby affirm that there Is a construction lending agency for _
the performance of the work for which this permit Is Issued CONTRACTOR
(Sec 3097,CIv. C}
ADDRESS
Lenders Name
arY TEL No. � �OLO:OtOC'�UD1 10A1124O1�1i!
Lendees Address STATE uC 6365 1 AM :26
I certtfy that I have read this application and state that the LICENSE NO CLASS
above Informatlon Is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
'and hereby authorize representativsa of this County to,enter
Aj. a e-mentlo operty for Inspection purposes.
TEE REVERSE FOR EXPLANATORY LANGUAGE
trn a Apsnt Dat