HomeMy Public PortalAbout6038 CLOVERLY AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION . APPLICATION FOR PERMIT
1 hereby affirm that I have a certificate of consent to self
Insure, or a certificate of Workers Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec 3800 Lab C ) 76A364C ti-
CE 818(REV 10/81)
Policy No Company
Certified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
Pol
❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
Tion department ADDRESS
(PRINT OR TYPE ONLY)
Date Applicant LOCALITY 7 ��/-1 L ' �✓
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS NEAREST
T 4
COMPENSATION INSURANCE CROSS
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 ) /
I certify that in the performance of the work for which this AIR HANDLING UNIT CFM L� �
permit Is Issued, I shall not employ any person In any manner r
so as to become subject to the Workers Compensation Laws BOILER BTU APPROVALS DATE INSPECTOR S SIGNATURE
w
Date Applicant COMPRESSOR BTU 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 VALIDATION
with comply with such provisions or this permit shall be
deemed revoked I FURNACE FAU GRAVITY'
LICENSED CONTRACTORS DECLARATION FLOOR BTU 1 0 I
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 d
O
License Number Lic Class , V
OG
Contractor Date O
H
❑ 1 am exempt under Sec a
Plan check fee H
B &P C for this reason
Date Z
PERMIT ISSUING FEE $
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12
Signature TOTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT IIS e-
I hereby affirm That I am exempt from the Contractor s License , 6 4 1 5 A
Law for the following reason (Section 7031 5 Business and NAME ( 3 L� I�-
Professions Code) lu
ADDRES + 1 , �iz+ o o o o o 8
El as owner of the property, or my employees with "��
wages as their sole compensation,will do the work and o o
thestructure is not mjtended'or offered for sale(Section CITY C'�^ TEL NO t l O 2 2 5 0
7044 Business and Professions Code) OWNER to 0 0 2 0 5'0
�L U
❑ I as owner of the property, am exclusively contracting ,
with licensed contractors to construct the project (Sec- MAIL ,l 0,2 8—8�
tion 7044 Business and Professions Code) ADDRESS
CONSTRUCTION LENDING AGENCY CITY TEL'NO
I hereby affirm that there is a construction lending agency for pop
ADDRESS
performance of the work for which this permit Is Issued CONTRACTOR
(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 to comply with all County
ordinances and State laws relating to building construction
and hereby authorize representatives of this County to enter
uyon the above-menti n d property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date r