HomeMy Public PortalAbout5806 CLOVERLY AVE_Mechanical__ �� 3� 1-1s y/� tI
QRS' COMPENSATION DECLARATION APPLICATION FOR PERMIT
FNo6j(1013_1�dmpany
that I have a certificate of consent to self
tlflcate of Workers' Compensation Insurance HEATING - VENTILATING - AIR CONDITIONING
p thereoof Sec 3800, Lab C ) /� CE 81CFsoutti A_r , CE 818(REV 10/81)
Certified copy Is hereby furnished i COUNTY OF LOS ANGELES BUILDIN AND SAFETY '
Certifi6d copy is filed with the co my building inspec- FOR APPLICANT TO FILL IN BUILDING C C�� j,,
tion department (PRINT OR TYPE ONLY) ADDRESS `"'��
I?dP
Date Applicant LOCALITY C
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM W9KERS NEAREST
COMPENSATION INSURANCE CROSS ST
(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 )
I certify that in the performance of the work for which this AIR HANDLING UNIT CFM L 0�
permit is issued, I shall not employ any person in any manner
so as to become subject to the Wo rs C091pensation Laws BOILER BTU APPROVALS DATE ' INSPECTOR S SIGNATURE
Dare - PPI Icon _4iL COMPRESSOR BTU �� QUp ROUGH
NOTICE TO APPLICANT If after making thi ertificate of� VENTILATION SYSTEMm - 4 FINAL--
' Exemption, you should become subject the Workers _
Compensation provisions of the Labor Code you must forth- EVAPORATIVE COOLER VALIDIIATION
with comply with such provisions or this permit shall be
deemed revoked FURNACE FAU RAVITY - _
LICENSED CONTRACTORS DECLARATION FLOOR BTU 1091
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
License Numbe Lic Class V
Contractor Date r '3 1 r fL - 0
j am exempt un r Sec 2
Plan check fee CL
N
B 8P C for this reason PERMIT ISSUING FEE $ z
Date ,
—Signature TOTAL FEE
OW ER BUILD LARATION PLAN CHECK APPLICANT
I hereby affirm that I am exerfifttofrom the Contractor s License "
Law for the following,reason (Section 7031 5, Business and NAME
Professions Code) -
❑ j, as owner of the property or my employees with ADDRESS z
wages as their sole compensation,will do the work and
CITY TEL NO T
the structure Is not intended or offered for sole(Section
7044 Business and Professions Code)
OWNER �o
❑ j, as owner of the property am exclusively contracting MAIL _
with licensed contractors to construct the project (Sec- ( ii
tion 7044 Business and Professions Code) ADDRESS tel" { _t, _3 4 2__a
CONSTRUCTION LENDING AGENCY CITY TEL NO � y Q ZC CHEK ,
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued r CONTRACTOR j C ,
(Sec 3097 Civ C ) _
ADDRESS
Lender's Name
CITY TEL
Lender s Address ZLW
STATE Q LIC (T �s (_
I certify that I have read this application and state that the LICENSE NO (J CLASS 1 Z0
above information is correct I agree to comply with all County
ordinances and State jaws relating to building construction
and hereby auth rize representatives of this County to enter -
upon e above° en oned property for Inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Apphc 1 or Agent Date '