HomeMy Public PortalAbout5024 CLOVERLY AVE_Mechanical__ WORKERS COMPENSATION DECLARATION APPLICATION FOR PERMIT 1
I hereby affirm that I have a certificate,of consent to self I � r _
insure, or a certificate of Workers Compensation Insurance, }76A364C f ;`r 1 HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec 3800 Lab C ) j
SCE 818(REV 10/61) ,
Policy No Company
Certified copy is hereby furnished 1 COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the county building inspec b FOR APPLICANT TO FILL IN - BUILDING SQ `
ADDRESS
tion department /
(PRINT OR TYPE ONLY) /
Date Applicant LOCALITY
CERTIFICATE OF EXEMPTION FR15M WORKERS NO TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREST
COMPENSATION INSURANCE CROSS ST
r ( ABSORPTION UNIT BTU DISTRICT NO PROCESSED BY
(This section need not be completed if the work involved by
the permit is for one hundred dollars'(5100)or less ) I AIR HANDLING UNIT CFM
I certify that iri the performance of the work for which this
permit is Issued,'I shall not employ any person in any manner
s0 as to become subject to the Workers Compensation Laws ' BOILER BTU APPROVALS DATE - N PECTOR S SIGAJATURE
Date Applicarit COMPRESSOR BTU 3� 0� e ROUGH
s
NOTICETO APPLICANT If after m6king this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers
Compensation provisions of the Labor Code you must forth i EVAPORATIVE COOLER VALIDATIO
with comply with such provisions'or this permit shall be
} deemed revoked w FURNACE FAU GRAVITY
_� LICENSED CONTRACTORS DECLARATION FLOOR .. BTU
I hereby affirm that I am licensed under provlsions�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 is in full forces and effect - _"' d
License Number 3 30 Lic Class S�-oC0 e V
Contractor to
❑ I am exe pt under Sec _ LU
Plan check fee If
N
B&P C for this reason Z
` - PERMIT ISSUING FEE $
Date LAI
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 , 2i2 2 7 9 A
Professions Code)
❑ j, as owner of the property or my employees with ADDRESS 3 w J # o i o 04 0'o 8
l wages as their sole compensation will do the work and CITY TEL NOS' 2 o e 3
the structure is not intended or offered for sale(Section 1 .� Jr d
x7044, Business and Professions Code) I IOWNER �s a o 0 3 0 5 0 c
Elj, as owner of the property am'excluslvely contracting MAIL t
with licensed contractors to construct the project (Sec - - s 0626-84
tion 7044 Business and Professions Code) ADDRESS-]
CONSTRUCTION LENDING AGENCY CITYr el TEL NO
I hereby affirm that there is a construction lending agency for ,
the performance of the work for which this permit is issued CONTRACTOR
(Sec 3097 Civ C )
ADDRESS - — -
Lender s Name
„ NO�S�s
Lender s Address CITY TEL
STATELIC
I certify that I have read this application and state that-the LICENSE NO ?476 CLASS _ - —
above information is correct I agree to comply with all County _
ordinances and State laws relating to building construction - T
and hereby authorize representatives of this County to enter
u on the above mentioned roperty f r inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
A 91
Sign re of Applicant or,Agent Date