HomeMy Public PortalAbout5622 CLOVERLY AVE_Mechanical__ c » ,'"},`WORKERS f.OMPENSATION DECLARATION, APPLICATION FOR ( PERMIT
I herebx affirm that I h%ve a ceetiflcate of consent to self, a t
Insure, or a certificate of Workers Compensgtion insurance HEATING - VENTILATING - AIR CONDITIONING
or cice;tlfle SSop thereof Sec 3800 b C ) 6A364C a F
jy ��/ 3 CE 818(REV 10/81)
Policy No'—(;, Company - - COUNTY OF LOS ANGELES - BUILDING AND SAFETY '
Certified copy is hereby furnishe
Certified copy is filed with the county building inspec FOR APPLICANT TO FILL IN - - BUILDING
tion ep rt nt (PRINT OR TYPE ONLY) ADDRESS F
LOCALITY
Date
V,
nT NO TYPE OF APPLIANCE OR EQUIPMENT FEE
c`
CERTIFICATE OF EXEMPTI FROM W RS NEARES
COMPENSATION INSURANCE CROSS S7 k
c ABSORPTION UNIT BTU
(This section need not be completed if the work involved by DISTRICT NOPROCESSED BY
the permit'is for one hundred dollars ($100)or less) `� ,Q� -��~
AIR HANDLING UNIT CFM J
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
so as to become subject to the Workers Compensation Laws APPROVALS DATE INSPECTOR S,SIGNATURE
COMPRESSOR BTU 600 6 0 ROUGH
Date Applicant / � l
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 VALIDATION
with comply with such provisions or This permit shall be ��Q�Q
'y deemed revoked, J FURNACE FAU G AVITY !
LICENSED CONTRACTORS DECLARATION / FLOOR BTU aP Oea
I hereby affirm that I,am licensed under provisions of Chapter 9 HEATER SUSPENDED 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
LicenseJNum `/ Lic Clas -- doil. U
/ Y�lOC
ContFactor s
❑ I am4xempt under c ,
Plan check fee � ` •� a
N
` B &P C for this reason_ PERMIT ISSUING FEE �� �•'j �'. Z
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 ► _ tY, _
Professions Code) ' - - hhrr
El --AC
ADDRESS C T a B I as owner of the property, or my employees with ��yy �-+,-y
wages as their sole compensation,will do the work and CITY TEL NO -307 � e0
the structure is not intended or offered for sale(Section ITEMS r
7044 Business and Professions Code) ? OWNER – - 1 ITEh1S
EJj, as owner of the property, am exclusively contracting [�'/ _MAILTT� i®m
with licensed contractors to construct the project (Sec ADDRESS) (�p�p�
tion 7044 Business and Professions Code) CHECK
CONSTRUCTION LENDING AGENCY CITY —� TEL "� �j l�f' CHOU
I hereby affirm that there Is a construction lending agency for r ttlK3G -
the performance.of the work for which this permit Is Issued CONTRACTOR �–
(Sec 3097 Civ C) _ + - -� -
ADDRESS 1 7'3t'` C - ({��ry�-��y�1 - 7/26/89
Lender s Name- to p
, CITY / _i EL NOa 6 _�� _ 4071 1 PM DO..
Lender s Address STATE /'C n_ --7 LIC
I certify that I have read this application and state that the LICENSE NO p / /�� CLASS C —
above information Is correct 'I agree to comply with all County
ordinances and State laws relating to building construction,
a hereby a horize representatives of this County to enter y
u o -mentione property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
,7./ 9—e�y I _
ignature of A46ant or Agent Date