HomeMy Public PortalAbout5751 CLOVERLY AVE_Mechanical__ WORKERS COMPENSATION DECLARATION APPLICATION FOR PERMIT
�I�herebp affirm that I have b certificate of consent to self
insure, or•a cc;tificateYof Workers'.Compensation Insurance - HEATING - VENTILATING - AIR CONDITIONING
or a &rtified copy thereo£,(Shc 38 0, Lob' 76A364C 1
��z�� ��^�psCE 818(REV 10/81)
Policy mpany C..-U
Certified copy is hereby furnished - COUNTY OF LOS ANGELES BUILDING AND SAFETY r
Certified copy is filed with the county building mspec- FOR APPLICANT TO FILL IN BUILDING
Tion de grim of ADDRESS
(PRINT OR TYPE ONLY),,
Date ApplicantLOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST A /
COMPENSATION INSURANCE - r CROSS ST
ti ABSORPTION UNIT BTU
(This S@CtlOn need not be completed If the work Involved by DISTRICT NO PROCESS Y y t
the permit Is for one hundred dollars ($100)or less`) A
I-certify that in the performance of the work for which this AIR HANDLING UNIT CFM
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 ,SPECTOR S SIG URE
Dare Applicant COMPRESSOR BTU-3-4 006 lQ t/O 'ROUGH
,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 VALIDATI N
with-comply 'with such provisions or this permit shall be
deemed revoked y _ FURNACE FAUYY ^
LICENSED CONTRACTORS DECLARATION - FLOOR , BTU j Q
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 L d
Lic Class
License Number
Contracto' r '" — at� v # 6 3 �,b g O
I am exempt under Sec # • e o 0 0 8 W
Plan check fee 911.
I e o
B&P C for this reason 44,50 HPERMIT ISSUING FEE (, Z
Date TOTAL FEE o 0 0 4 [I 50 v
Signature _
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT ° 0 7.0 7`87 '"
I hereby affirm that I am exempt from the Contractor s hcen'se - -
Law for the following reason (Section 7031 5 Business and NAME pool
Professions Code) r a
ElI 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 TEL NO
7044 Business and Professions Code) N ,
E] 1,
I, as owner of the property am exclusively contracting
with licensed contractors to construct the project (Sec- 'MAIL
Tion,7044, Business and Professions Code) ADDRESS
CONSTRUCTION LENDING AGENCY CITY
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 ) _ - ti -
ADDRE!j��& /V. 0 * r T,
Lendens Name
CITY _ TEL NO�
Lender s Address STATE �7,[� cLIC
I certify that I have read,this application and state that the LICENSE NO / 7 �Q 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 '
upon theabove-me
iiioneed�property for inspplc Iionnpp
}ur
poses SEE REVERSE FOR EXPLANATORY LANGUAGE
"'tel � C✓��ll�C.icT/t � ! V i , • ` y -
Signature of Applicant or Agent Date J `
i