HomeMy Public PortalAbout6044 CAMELLIA AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION CEA 818 C(2-80) A PP L ICAT�O N FOR !!—E R IVII T
I`hereby affirm that I have a certificate of consent to self "'fl
insure, or a certificate of Workers'Compensation Insurance,or HEATING-VENTILATING-AIR CONDITIONING
a certified cppy thereof(SSc. 3800, Lab.C.)
Policy No._ Coktpan
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I� Certified py is hereby furnished.
COUNTY OF LOS ANGELES BUILDING ARID SAFETY
r co '.
Certified copy is feed with the county bull ding hi;pectio❑ FOR APPLICANT TO FILL IN BUILDING
depe-tment.
Date Applicant (PRINT OR TYPE ONLY) ADDRESS
LO-CALITY
CERTIFIC!CTE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE C
COMPENSATION-INSURANCE - NEAREST
(Thlr section.neeNd.not be 'completed if the work ihyotved ABSORPTION UNIT, BTU CROSS ST.
by, the pgrmit• is for one hundred dollare ($10Q) or doss.) D19TRICT NO.�/. PR ED BY 8
I I certify that in the perf9rmance of the work for which this AIR ANDLING UNIT CFM \�
permit is Issued, I shall got'employ any person In any manner JVL
51
to a1 to become subject"to the Workers' Compensation Laws. BOILER BTU O
4 APPROVALS DATE INst'ECTOR'9a10NATURE CUUU-
Date Applicant COMPRESSOR BTU LU
ROUGH
NOTICE TO APPLICANT:PPLICNT: If, after making this Certificate of VENTILATION SYSTEM 95
FINAL 6 2
Exemption, you should become subject.,Io the Workers' _
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER
with comply with such provisions or,this petmit ahall be VA IDATION
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTR'AC'TORS DECLARATION ) ' FLOOR: BT
f' I hereby affirm that I am licensed under provisions of Chapter HEATER: SUSPENDED UNIT
9'(commencing with Section 'j000) of Division 3 of the Busl- WALL
I neas and Professions Code, and my llcame Is In full forte and
effect.
License Number- Lic. Clam
50
EContiactor Date
I am exempt from the licensing requirements as I am a
_ ticensed uchttect or a registered professional engineer Plan-ehnk fee 25%of above.
acting in my professfonat•capacity (Section 7051, Burr
mess and Professions Code). PERMIT ISSUING FEE$
Lic.or Res.No. -Date TOTAL FEE IV A71
HOME OWNER-BUILDER DECLARATION PLAN CHECk APPLICANT
I hereby affirm that I ■m exempt from- the Contractor's NAME
License Law for the following rgaon (Section 7031.5, Busl- -
ness and Professions Code): ADDRESS _
JL
I, as owner of the property, will do the work and the �4�tyy
atructuro Is not intended or offered 'for sale (Section CITY TEL. NO_ =7 48 W
7014, Business and Profasalons Code). i. ..._ ... ---
OWNER ITM
Nction
s owner of the property, am exclusively contracting
h licensed cogtractors to construct the project MAIL 'TOTAL 48.00
• 7044, ausinesa and Professions Code). ADDRESS40T 1 -
CONSTRUCTION LENDING AGENCY CITY CK 48
TEL.NO. 7 7
L{>L .00
I hereby affirm that there is a construction lending agency NE aW
for the performance, of the work for which this permit Is CONTRACTOR 1.W
issued (Sac. 3097,Civ.C.).
Lender's Name . - - ADDRESS — — - t/gyp
Lander'sAddress CITY TEL NO.
_000IMM1 T'8i
•
I certify that I have rand this application and state that the STATE LIC. 1 AM 9:2b
above Information h correct. I agree to comply with all County E Ng., CL
ordinances and State laws regulating I-(eating, Ventilating and
Air Conditioning, and hereby authorise representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE
County to enter upon the above-mentioned property for
his do es.