HomeMy Public PortalAbout6002 CLOVERLY AVE_Mechanical__ .�"", WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
11heigby clffirm that I have a certificate of consent to self
• •4,9ure,'o`i q certificate,of lNorkers' Compensation Insurance, HEATING - VENTILATING .- AIR CONDITIONING
or a certified copy thereof (Sec. 3800, Lab. C.) 76A364C
CE-818(REV. 10/81)
Policy No. Company
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. (PRINT OR TYPE ONLY) ADDRESS
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEARESST.
COMPENSATION INSURANCECROSS
ABSORPTION UNIT, BTU DISTRICT NO. PROCESS D B
(This section need not be completed if the work involved by
the permit is for one hundred dollars ($100)or less.) /I r/
AIR HANDLING UNIT, CFM v d
1 certify that in the performance of the w which this
permit is issued, I shall not employ a erson in any anner BOILER, BTU
so as to become subject to the W ers'Compensation Laws. APPROVALS DATE INS TOR'S SIGNATURE
COMPRESSOR, BTU ROUGH /
Dat/_O pplic nt
NOTICE TO APPLICANT: If, a ter ma ing this Certificate of VENTILATION SYSTEM FINAL 37 — �•
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDA ON
with, comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9SUSPENDEDoe-- UNIT
HEATER:
'(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code,and my license is in full force and effect.
r 0
O
License Number Lic. Class poll. V
Contractor Date
❑ I am exempt under Sec. IU
Plan check fee 9L
B.&P.C. for this reason H
PERMIT ISSUING FEE $
Date: TOTAL FEE Q
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby.offirm that I am exempt from the Contractor's License
Law r the following reason (Section 7031.5, Business and NAME D z 3 3 2 5 A
Pro ssions Code):
I, as owner of the property, or my employees with ADDRESS ��/ Z ®�/ � # o a a o 0 8
wages as their sole compensation,will do the work and CITY TEL. NO. �y.�Q�
the structure is not intended or offered for sale(Section /✓ ° o20.50
7044, Business and Professions Code).
OWNER ° ° - 2050'.
❑ I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL
ADDRESS Q 2 9 8 5
tion 7044, Business and Professions Code). —
CONSTRUCTION LENDING AGENCY CITY TEL. NO.
1 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.).
ADDRESS
Lender's Name �f
./Jjy wJ CITY TEL. NO.
Lender's Address
STATE LIC.
I certify that I have read this application and state that the LICENSE NO. CLASS
above information is correct. I agree to comply with all County
ordinances atrtLfws'Tely\ing to building construction,
and h y authorize rep esent'tives of this County to enter
u the ab e- entio erty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agen Date