HomeMy Public PortalAbout4815 CLOVERLY AVE_Mechanical__ gORKERS COMPENSATION DECLARATION APPLICATION FOR PERMIT
I�hereh(y_q(fwcn That,l have a certificate of consent to self
nsLie orgceis"ficaTerof Workers
Compensation Insurance 76A364C HEATING - VENTILATING - AIR CONDITIONING
or,a certified copy thereof(Sec 3800, Lab C )
CE 818(REV 10/81)
Policy No Company COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy Is hereby furnished
❑ Certified copy Is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING y
tion department s (PRINT OR TYPE ONLY) ADDRESS C�LfJ����[yf Ji lvz
Date Applicant LOCALITY ��M /1Le �_["r/
NO TYPE OF APPLIANCE OR EQUIPMENT FEE 9
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST , ! �✓ v��
COMPENSATION INSURANCE CROSS ST `—(!
(This section need not be completed if the work involved by ABSORPTION UNIT BTU DISTRICT NO PROC Y
the permit is for one hundred dollars ($100)or less ) AIR HANDLING UNIT CFM `
I certify that in the performance of the work for which this r
permit is issued, I shall not employ any person in any manner ,
- so as to beOs subject to the W�s Compens ion Laws BOILER BTU APPROVALS DATE INS CTOR S SIGNAT RE
PP
Date • Itca / COMPRESSOR BTU Z— ROUGH
NOTICE TO APPLICANT If after making this Certifi of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked FURNACE FAU V GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU /
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT+ 41:2
(commencing with Section of Division 3 of the Business HEATER WALL n
and Professions Code and myy license is in full force and effect CL
License Number Lic Class ' V
0
Contractor Date - 0
IDI am exempt under Sec y�V
Plan check fee d
N
B 8P C fort is reason
Date �
PERMIT ISSUING FEES O _
Signature _ TOTAL FEE 1
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor s License ,
Law for the following reason (Section 7031 5 Business and NAME
PP ffessions Code)
L}0 I as owner of the property or my employees with ADDRESS s �U j1,5r
/1 wages as their sole compensation will do the work and -��^Sm C f p
the structure is not Intended or offered for sale(Section CITY / S Je_ 7-1 TEL NO 28/7_(j&V�
7044, Business and Professions Code) OWNER 4 6 0'3,7 A
❑ I as owner of the property am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL # 0 0 0 o e 8
tion 7044 Business and Professions Code) ADDRESS ) 0 - 4625
CONSTRUCTION LENDING AGENCY CITY TEL NO
1 hereby affirm that there is a construction lending agency for e 0 e 4 6,2 5 0
the performance of the work for which this permit Is issued CONTRACTOR j 00.(Sec 3097 Civ C ) 1 20 1 .i
8 6
ADDRESS
Lender s Name
CITY TEL NO
Lender s Address
I certifythat I have read this application and state that the STATE LIC
pp LICENSE NO CLASS
above information is correct I agree to comply with all County
ordinances and State jaws relating to building construction
4neby authorize representatives of this County to enter
e abov -meioed property for inspection purposesSEE REVERSE FOR EXPLANATORY LANGUAGEof Applicant or Ag t �-
r i