HomeMy Public PortalAbout5428 CLOVERLY AVE_Mechanical__ 7 4-WORK-ERS 'COMPENSATION DECLARATION APPLICATION FOR PERMIT
here:Z aff�ngthat have a certificate of consent to self
t+nsure,ior.o certificate of Workers' Compensation Insurance 76A364C HEATING - VENTILATING - AIR CONDITIONING
or a certefi o th r 9i(Sec 3800, L b )
� CgJ CE 818(REV 10/81)
Polec o "��9 empany
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
tion department /'n / �,t !"V (PRINT OR TYPE ONLY) ADDRESS
Date Applicant ifLL%��'1Y/���//nY. LOCALITY 725�mr0e C G`�T
NO TYPE OF APPLIANCE OR EQUIPMENT FEE 'C
CERTI KATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE L CROSS ST Q/-/VAG
(This section need not be completed if the work inv ed by ABSORPTION UNIT BTU DISTRICT NO PROCESSED BY
the permit is for one hundred dollars (5100)al.0
r s ) (/
I certify that in the performance of the r which this AIR HANDLING UNIT CFM
permit is Issued, I shall not employ any rson any manner BOILER BTU U
so as to become subject to the WOr S Compensation Laws APPROVALS DATE INYECAR S SIGN URE
Date Ap ant COMPRESSOR BTU a Uv ROUGH 7
NOTICE TO APPLIC If, after making this Certificate of VENTILATION SYSTEM FINAL
Ezemptton, yo ould become subject to the Workers
Compensate provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDA N
with co y-with such provisions or this permit shall be
dee d revoked FURNACE FAU RAVITY
LICENSED CONTRACTORS DECLARATION FLOOR TU �D(/ D-
I hereby affirm that I cim licensed under provisions of Chapter 9 HEATER SUSPENDED UNIT(commenting with Section 7000) of Division 3 of the Business WALL
and Professions Code,and my license is in full force and effectCL
�`O ^L/�} }
License NumLer glr3i?70 Llc Class Ca Q f/ O
�e
Contractor Date
^ MI am exempt under c W
Plan check fee CL
B &P C for this reason - PERMIT ISSUING FEE S 6 ;28022A Z�
D`�tJ
Signature �i'�4' - TOTAL FEE # e'o • • 0 8
OWNER BUILDER DECLARATION PLAN CHECK APPLICANT ,I -1- 41L50
I hereby affirm that I am exempt from the Contractor s Li e ►
Law for the following reason (Section 7031 5 B ss and NAME
Professions Code) _ o,o • 4 4,5 05
❑ I as owner of the property, my employees with ADDRESS
wages as their sole compe on,well do the work and CITY TEL NO - 0929-87
the structure is not int ed or offered for sale(Section
7044 Business a rofesseons Code) E
OWNER
' ❑ I, as ow of the property, am exclusively contracting
wit ensed contractors to construct the project (Sec MAIL ¢
n 7044 Business and Professions CcFd ADDRESS �J
CONSTRUCTION LENDING AGE E CITY TEL NO f-633
j hereby affirm that there is a construct lending agency for
the performance of the work for ech this permit is issued CONTRACTOR
(Sec 3097 Civ C )
ADDRESS
Lender's Name
CITY TEL NO ,
Lenders Addr
STATE ,/� LIC
I certify at I have read this application and state that the LICENSE NO (./ CLASS _Cc? C7
abov/information is correct I agree to comply with all County
ordinances and State jaws relating to building construction,
olid hereby authorize representatives of this County to enter '
upA`b vi ;pe0
rty finspection purposes i
SEE REVERSE FOR EXPLANATORY LANGUAGE ,
Signature of Applicant or Agent Date V