HomeMy Public PortalAbout5426 CLOVERLY AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT
L hereby Affirm that I have a certificate of consent to self
Insure, of a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
tlfled coy thereof (Sec 3800, Lob C ) �• 76A364C
Y --= Company � �`i— 20 0046 DPW 9/88"
a11c o
❑
Certified,ed,copy Is he eby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
XCertified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tlo cl artmeni ADDRESS
(PRINT OR TYPE ONLY)
/7
Date Applicant y NO TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY J
CERTIFICATE OF,EXEMPTION FROM WORKERS NEAREST
- COMPENSATION INSURANCE CROSS ST
PROCESSED BY
' (This section need not be completed if the work involved by ABSORPTION UNIT BTU DISTRICT NO P��''/
the permit is For one'performance
of t work
`or less)
AIR HANDLING UNIT CFM
I certify that In the performance of the work for which this i
' permit is Issued, I shall not employ any person in any manner
so askto become subject to the Workers Compensation Laws, BOILER BTU APPROVALS DATE INSPECTOR S SIGNATURE
-• ' R r e g II r 0
Date Applicant COMPRESSOR BTU ROUGH
NOTICE TO'APPLICANT If, after making this Certificate of VENTILATION SYSTEM FINAL �.tdy
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 deem- '
ed revoked I , FURNACE FAU GRn O
LICENSED CONTRACTORS DECLARATION FLOOR BTU 6!
I hereby affirm that,l am licensed under provisions of Chapter 9 HEATER SUSPENDED ONIT-
(commencing with Section,7000)of Division 3 of the Business WALL
and Professions Code,and m, II ense Is In fu r �nd effe
License Number Alp LIc�C ass , O
Contractor / 'Date `
❑ I am exempt under Sec O
Plan check fee u
W
B&P C for this reason H
Date PERMIT ISSUING FEE $ Z
TOTAL FEE
Signature
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
Professions Code) ,
El j, as owner,of the'property, or my employees with ADDRESS- _ i
• a
wages as their sole compensation,will do the work and i Wit-- 'g
the structure is not intended or offered for sale (Section, CITY TEL NO r ' 7 `r a1
7044, Business and Professions Code) OWNER
F-1 1, as owner of the,property, am exclusively contracting a i SEN:
with licensed contractors,to construct the project (Sec- MAIL ,t-�,��
tion 7044, Business and Professions Code) ADDRESS ttti � '
y CONSTRUCTION LENDING AGENCY, CITY TEL NO -' ►CL,
I hereby affirm that there is a construction Iendlng3agency for r 4tt
the performance of the work for which this permit Is issued CONTRACTOR A t> hili'}I= eE!'_i
(Sec 3097, Civ C ) ' °
ADDRESSLenders Name r �J�� tltf;l I!�-1]ii[ ;r'=(�
CITY TEL NO /J
Lender's Address "*,ng
I certifythat I have read this application and state that the STATE LIC zt � ? i 10. t'?
PP LICENSE'NO CLASS
above information is correct I agree to comply with all County
ordinances and State jaws relating to building construction,
and hereby authorize representatives of this County to enter
ab v -mentioned property for insp9elon p rpeses;
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent ate _