HomeMy Public PortalAbout6027 CLOVERLY AVE_Mechanical__ WORKERS COMPENSATION DECLARATION 4
hereby affirm that I have a certificate of consent to self 1 APPLICATION FOR PERMIT
Insure ora certificate of Workers Compensation Insurance
or a certified copy thereof (Sec 3800, Lab C76A364C HEATING - VENTILATING - AIR CONDITIONINe,,► 5j3/Ir 7
) CE 818(REV 10/81)
Policy No Company COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished
❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING /' �j ♦/
tion department ADDRESS
(PRINT OR TYPE ONLY)
Date Applicant LOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS', NEAREST
COMPENSATION INSURANCE CROSS ST
ABSORPTION UNIT BTU DISTRICT NO PROCESSED BY
(This section need not be completed if the work involved 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 manner BOILER BTU
so as to become subject to the Workers'Compensation Laws APPROVALS DATE OR S SIGNATURE
Da114__..Z1 -;57Applicant COMPRESSOR BTU l0 ROUGH /
NOTICE TO APPLICANT If, after making this Certificate of VENTILATION SYSTEM U FINAL
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 G AVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU 92k CZ 0 10
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
Z 0
License Numb e Lic Class OV
OC
Contractor pate / 0
❑ I am exempt under Sec _ uVi
Plan check fee h
B &P C for this reason
Date $A
PERMIT ISSUING FEE $ / -9 6 8 9.2 A —
Signature TOTAL FEE (� # 0 0 010 e 8
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT , * 4270
I hereby affirm that I am exempt from the Contractor s License - Poo.Law for the following reason (Section 7031 5 Business and NAME o,0,o 4 2 7 0-5
Professions Code)
❑ I as owner of the property or my employees with
ADDRESS 0422is87
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)
OWNER
❑ 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 C22
CONSTRUCTION LENDING AGENCY CITY TEL N Lbw,
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is Issued CONTRACTOR S ,
(Sec 3097, Civ C ) -
ADDRESS
Lender's Name 60
CITY TEL_NO
Lender s Address .,
I certifythat I have read this application and state that the STATE _ LIC y
pp LICENSE NO CLASS-
above information is correct I agree to comply with all County
ordinances and State jaws relating to building construction -
and hereby authorize representatives of this County to enter
upon the above entii d property for
,inspection
�purposes _ SEE REVERSE FOR EXPLANATORY LANGUAGE
ti _
Signature of Applicant or Agent Date