HomeMy Public PortalAbout5338 CLOVERLY AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION W `" APPLICATION L FOR PERMIT
I hereby affirm that I have a certificate of consent to to self �
insure, or a certificate of Workers Compensation Insurance HEATING - VENTILATING - AIR CONDITIONING
mor a certified copy thereof (Sec 3800, Lab C ) 76A364C
CE 818(REV 10/81)
Policy No d37C�mpanyl;9ee,0- "-I"
r Certified copy is hereby furnished COUNTY OF LOS ANGELESILI BUILDING AND SAFETY
Certified copy is filed with the county building risplk FOR APPLICANT TO FILL IN BUILDING
tion department ADDRESS 3 CJ ti0 C
(PRINT OR TYPE ONLY)
Date — S 3 Applicant LOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE `
CERTIFICATE OF EXEMPTION FROM ORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST V `d/e
(This section need not be completed if the work involved by ABSORPTION UNIT BTU DISTRICT NO . PROCESSED BY
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
permit is issued, I shall not employ any person in any manner BOILER BTU Ly� ODL /
so as to become subject to the Workers Compensate n L s ` ' APPROVALS DATE INS OR S SIGNATURE
Date �✓ Applicant COMPRESSOR BTU ROUGH
NOTICE TO APPLICANT If after making 1 (s 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 FAU GRAVITY rte--- l�
LICENSED CONTRACTORS DECLARATION FLOOR BTU I v
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 is in full force and effect >'
d
License NumberY,;�-2"1 rr Lic Class , U
X
ntractor Date/�� s !�3 O
❑ ,
I am exemptn _ ~
der Sec W
Plan check fee
B&P C for this reason g 7 3 G,2 A Z
- - PERMIT ISSUING FEE $ _
Date # o a o e o 8
Signature TOTAL FE_E Z+U ,
OWNER-BUILDER DECLARATION - PLAN CHECK APPLICANT 2 °,° 2 0 5 O
1 hereby affirm that I am exempt from the Contractor's License , 2 0 5 0
Law Professions Code) oto 0 for the following reason (Section 7031 5 Business and NAME
12,05-83
El1, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and '
the structure is not intended or offered for sale(Section CITY vim- TEL NO 3 C _70a
7044 Business and Professions Code)
OWNER
ElI as owner of the property am exclusively contracting
with licensed contractors to construct the project (Sec MAILC/f
S tion 7044 Business and Professions Code) ADDRESS �J � I t
CONSTRUCTION LENDING AGENCY CITY / TEL N�JS 'X�
1 hereby affirm that there is a construction lending agency for /a
the performance of the work for which this permit is issued +CONTRACTOR S
(Sec 3097, Civ C ) n
Lender's Name ADDRESS
w
Lenders Address
CITY ' r TEL NO 34- X100) _
STATE LIC
�)
I certify that I have read this application and state that the LICENSE NO —7 1J CLASS / -
above information is correct I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter
upo` the above-menti ed rope ty for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
ZZ
Signature of Appl ant or Agent Date '