HomeMy Public PortalAbout6006 CLOVERLY AVE_Mechanical__ 1 WORKERS' I,hove COMPENSATION DECLARATION APPLICATION FOR PERMIT
insdrt',herebor'a cerVif cay offirm tte of Workers'certificate
on Insuranceent to ,
or r�J*rtnsie,'.copythereofr( ec. 3800, Lab. C.) CE_81C HEATING - VENTILATING - AIR CONDITIONING
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 / 00
tion department. (PRINT OR TYPE ONLY) ADDRESS (O (/(O
Date Applicant LOCALITY Tm e G ft
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE I �
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST / /
COMPENSATION INSURANCE CROSS ST. ��A ✓N �F Nell
(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.)
AIR HANDLING UNIT, CFM ,(
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any,r`�anner
so as to become subject to the Work rs Compensat oh Laws. BOILER, BTU APPROVALS DATE INSP TO S SIGNATURE
�, ��J�a/ COMPRESSOR, BTUWOO Id ROUGH
Date � Applicant -
id
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. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU SZC2,0 (� (�
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 Number Lic. Class ► U
Contractor Date O
a-
❑ I am exempt under Sec. V
Plan check fee
B.&P.C. for this reason
Date: PERMIT ISSUING FEE $ Z
Signature m
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 Ko v,- t ' 4 9 U 7 A
Professions Code): ; 1
r V o a o 0 a
El 1, as owner of the property, or my employees with ADDRESS 3 �� 1Y�1 (j f� Tom`
wages as their.sole compensation, will do the work andV`] ��� VT) ( 0 0 3050
the structure is not intended or offered for sale(Section CITY C TEL
NO. % �
7044, Business and Professions Code). OWNER J� 1y o 0 0 3 Q 5 0
[L�JI J 'C._
I, as owner of the property, am exclusively contracting MAIL 0 7.0 2 t 8 6
with licensed contractors to construct the project (Sec- MAILADDRESS
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TEL. NO.
I hereby affirm that there is a construction lending agency for '
the performance of the work for which this permit is issued CONTRACTOR �. .Jr,_
(Sec. 3097, Civ. C.).
ADDRESS
Lender's Name
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 t omply with all County
ordinonc and State laws r lating o building construction,
and her 6' authorize repres tative o this County to enter
upon t boy -Ttione r Oy o inspection purposes (/o SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date