HomeMy Public PortalAbout4850 CLOVERLY AVE_Mechanical__ I WORKERS COMPENSATION DECLARATION 'APPLICATION FOR PERMIT
I hereby affirm that,_1 have a certificate of consent to self ) r
Insure, or a certificate of Wo}Rers Corhpensation Insurance, 76A364C HEATING - VENTILATING - AIR CONDITIONING s
or a certified is thereof (Sec 3800, Lab C )
Pl)cy No 1 �Company 5 `C 20 0046 DPW 9/88� y
! Certified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
11
❑ Certified copy Is filed with the county building'Inspec- FOR APPLICANT TO FILL IN BUILDING 'J 10 Zyr Ur�
tion d art nt (PRINT OR TYPE ONLY) _ ADDRESS i
Date AppIicantz/ �vr �� LOCALITY ` S
NO TYPE OF APPLIANCE OR EQUIPMENT - FEE
C RTIFI ATE OF EXEMPTION FROM WORKERS NEAREST
w COMPENSATION INSURANCE CROSS ST Ce o" Z ,
(This section`need not be corn leted If the work involved by ABSORPTION UNIT BTU
p BDISTRICT NO ' PRQeESYD BY
the perm
it is for-one hundred dollars ($100) or less)
I certify that In the performarice of the work for which this AIR HANDLING UNIT CFM' �,
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permit Is Issued, I shall not employ any person In any manner,, '
'so as totbecome subject to the Workers Compensation Laws BOILER BTU APPROVALS D T INSPECTORS SIGNATURE
a 3F i COMPRESSOR BTU l ROUGH 1 C 0 �^fr
Date 'Applicant / n
NOTICE TO APPLICANT 0Ifsaftei ma'kin'g this'Certificate of VENTILATION SYSTEM FINAL
Exemption, yowl should become subject to the Workers
Compensation'provisions of the LabortCode, you must forth. EVAPORATIVE COOLER • VALIDATION
with comply with such provisions or'this permit shall be deem-
ed revoked . FURNACE FAU GRAVITY
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LICENSED'CONTRACTORS DECLARATION FLOOR BTU -
Fhereby affirm that jam licensed under provisions of Chapter 9 HEATER SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business WALL }
' and Professions Code;and my license Is in full force d effect
License Number Llc Class Q ld C/_Va
y _//
_ O
Contracto �A_0 /�
❑ O
I am exempt under Sec
Plan check fee v
W
B&P C'for this reason H
`, Date' PERMIT ISSUING FEE $ Z
t TOTAL FEE
Signature
01511)
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 —f
Professions Code) u `r
1, as owner 'offthe property, or my employees with ADDRESS-- Ail i•�
°s
wa es as their sole compensation,will do the work and n
thestructure is not intended or offered for sale(Section CITY-- TEL NO _',307 ?0°5V'�11
7044, Business and Professions Code) OWNER 1 ITEMSS
❑ 1, as owner of The property, am exclusively contracting r ' 20 . 50
�y �6
with licensed contractors to construct the project (Sec- MAIL ` T6TAU
2050
AU
tion 7044, Business and Professions Code) ADDRESS.,..., _ I � :a
CONSTRUCTION LENDING AGENCY CITY TEL No CHECK '10.50
I hereby affirm that there Is a construction lending agency for - , CHANGE °00
the performance of the work for which this permit is Issued CONTRACTOR
(Sec 3097, Civ C ) 1
ADDRESS
Lender's Name " ''r`' ._ 00CI0-0001 _ 1+J_0/89
T _ v y.
CITY TEL NO, p
Lender's Address
737, 1 AM 9:7
LIC
cert) that I have read this application and state that the STATE CL
certify PP LICENSE NO CLASS
above Information is correct I agree to comply with all County
ordma es and State laws relating to building construction,
and eby authorize pr sentatives of this County to enter
u e abo -m on prop ty r mspec Ion urposes - ,
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of App'hca or Agent D to Oe