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Home My Public Portal About5010 CLOVERLY AVE_Mechanical__ WORKERS COMPENSATION DECLARATION APPLICATION ,FOR PERMIT IF hereby, affirm that I have a certificate of consent to self Ins re, of o certlflcate of Workers' Compensation Insurance, HEATING = VENTILATING - AIR CONDITIONING or a certified copy there o (Sec 3800 Lab nC ) T 7E 818 ///�� 3� A1 �/c l6� l CE 818(REV 10/81) P❑olli`y Rio ompany 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 C O /v(�/ tion department (PRINT OR TYPE ONLY) ADDRESS J U /�Iv�, (0 Date C Applicant LOCALITY NO TYPE OF APPLIANCE OR EQUIPMENT FEE CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST COMPENSATION INSURANCE I CROSS ST ABSORPTION UNIT BTU DISTRICT NO PR SED B (This section need not be completed if the work involved by the permit is for one hundred dollars (;100)or less ) r AIR HANDLING UNIT CFM D I certify That in the performance of the work for which this permit Is Issued, I shall not employ GTJYloy,any_person_in any manner, so to become sublect to the Workers Compensation Laws BOILER BTU as APPROVALS DATE INSPECTOR S SIRE t Date Applicant I COMPRESSOR BTU 36E dOO 'lo ROUGH 1 NOTICE TO 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 VALIDATI N with comply with such provisions or this permit shall be deemed revoked FURNACE FAUY LICENSED CONTRACTORS DECLARATION r FLOOR BTU RAVIT I hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED—UNIT— (commencing USPENDED UNIT(commencing with Section 7000) of Division 3 of the Business WALL and Professions Code and my license license Is in full force and`effect y per, License Number /Q -3w _!� Llc Class C� ► V Contractor Date O t- ❑ I am exempt under Sec U Plan check fee a B&P C for this reason Z PERMIT ISSUING FEE $ pIf Date Signature TOTAL FEE 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 00. -'5 2 7,8 A Professions Code) ❑ 1, as owner of the property, or,my employees with ADDRESS # 0 0 0 • 0 8 wages as their sole compensation will do the work andCITY TEL NO` I o o 3 0,5 0 the structure Is not Intended or offered for sale(Section 7044 Business and Professions Code) 2 �� - OWNER - ° ° 0 3 Q 5 0,5 ❑ 1, as owner of the property, am exclusively contracting t with licensed contractors to construct The project (Sec- MAIL /I Q 8 1 9_8 6 Tion 7044, Business and Professions Code) ADDRESS O ` P�� CONSTRUCTION LENDING AGENCY CITY �r� �! TEL NO a 7c/Z I hereby affirm that there is a construction lending agency for the'performance of the work for which this permit is issued t P P CONTRACTOR �ON G r ON (Sec 3097 Civ C ) � - - P- - - - -- -- ADDRESS q_ A) Lender's Name _ 7 Lender's Address 7' CITY `PM /P �'� TEL NO yy STATE 7-7 _ I certify that I have read this application and state that the LICENSE NO j5/ J ! - CLASS C99 - - - - above information is correct 1 agree to comply with all County ordinances and State laws relating to building construction and hereby authorize representatives of this County to enter upon the above mentione roperty for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE & A-/,/-Oa - Signature of Applicant or Agent Date f