HomeMy Public PortalAbout6155 CAMELLIA AVE_Mechanical__ s' COMPENSATION DEC APAT10-N L APPLICATION FOR P E RM I T
c affirm that I have a certificate of consent to self 7��
Insure, cr a certificate of Workers' Compensatlon Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certlflbd copy thereof Sec 3800, Lab. G)
GG 3'�OC146 DPW 9/88
Poll ���t i`K I ny ' �� ?
Certified copy Is hereby furnished. I O J COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy Is filed with the county building Inspec- FOR APPLICANT TO FILL IN
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Bu
tion drtmenm
(PRINTORTP )
Date Applicant � e. A` �a LTM
C(RT
1dCE OR K]UIPMENT FEE
IFICATE OF DCEMPTICKJ FROM WORKERS' NO. TYPE OF APPUANEAREST
COMPENSATION INSURANCE /fn / O
CROSS ST.
(This section rssad not be completed if the vrork Invohrad by ABSORP1lON UNIT, BTU f<</'' DWROCT NO. FROCK BY
the permit Is for one hundred dollars (=100) or lots.) ' AIR HAfDUNG UNIT, CFM
I certify that in the performance of the work for which this
permit Is Issued, I'shall not employ artyom n In any manner
so ast6 become subject to the Workerspensatlon Laws. BTU naQRa`tis DATE uuarcrorrs sicrUnx:f
DateApplicant COAAPRESSOR, BTU ROUGH
NOTICE fO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption," you'should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER DA
wlthcompI with such provlslons or this permit shall be deemVU
-
ed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARAT16N FLOOR BTU
I hereby affirm that I.arn licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT-
(commencing-with Section 7000)of Division 3 of the Business WALL
and ProfessionkCade,and my license Is In.fulI force and effect.
7 y z y�� I Ic. Class— o
License Nu/m�b/erT
U
Contractor/% � e �
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El - I am exempt under Sem
Plan check fee LU
CL
B.&P.C. for this reason j
PERMIT ISSUING FEE ;
Date. TOTAL FEE
Signature
IR-BUILDER D ON RAN CHECK APPLICANT
I hereby affirm that I am exempt from tKe Contractor's License pop.Law for the following reason (Section 7031.5, Business and NME A1
Piofesslons Code):
I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and TELTofr
the structure Is not Intended or offered for sale(Section CITY 3W7 39.25
7044, Business and Professions Code). OWNER
I, as owner of the property, am exclusively contracting � 1 ITEMS
with licensed contractors to construct the project (Sec- MAIL 6 1 S' L a �y
tion 7044, Business and Professions Code). TOTAL 37 .G5
CONSTRUCTION LENDING AGEN CrTyC t TEL NO. ��
�j-- �
I hereby affirm that there Is a construction lending agency for G
the performance of the work for which this permit Is Issued COWRACTOR Xg., C , `. s00
(Sec. 3097, C1 v. G} � /Zd
Lenders Name
CITY TEL No. -60-7 y -QOID 1 5n4/89Lendei's AddressSTATE 7 i� ,s,
I certify that I have read this application and state that the NO-44Y7q. UCLAM e 9C/ 3510 1 AM11:20
above Information Is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize representatives of'thls County to enter
upon the a m Ingon property for Inspectlo purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
gnatvre o4 Applicant or Ageor