HomeMy Public PortalAbout5226 DEGAS AVE_Mechanical__ WORin that
Ihave COMPENSATION DECLARATION _ APPLICATION
PPL ICA TION FOR PERMIT
Y hereby q certificate
I have r certificate of cion Int to self P'Y IL /`Y Y�I IVY
-orsarc ore copy
Workers' Compensation Insurance, 76A364C - HEATING - VENTILATING - AIR CONDITIONING
or o certified copy thereof'(Sec. 3 0, Lob. ^,
Gy C ! yy 4 W,3Y WA CE-818(REV. 10/81)
s
P90
olicy N rt Company COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished.
�rtified copy is filed with the county building inspec- - FOR APPLICANT TO FILL IN BUILDING C��G C �
do depar Ment. ADDRESS J
ZZ ''� l r (PRINT OR TYPE ONLY) `
Date j Applicant_(im ✓4lN �`�J� LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CER IFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE - - CROSS ST. CjLIJ!/V
(This section need not be completed if the work involved by ABSORPTION UNIT; BTU D¢*Isla No. PROCEs
the permit is for one hundred dollars ($100)or less:)
(� o
I certify that in the performance of the work for which this .AIR HANDLING UNIT, CEM
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Lows. BOILER, BTU APPROVALS DAh INS P[ R'S SIGNATURE
Date Applicant COMPRESSOR ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILA YSTE FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EV ATIVE R VALIDAT
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR - BTU
I hereby affirm that 1 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 farce and effect.
License Numb,�er / 3 S6f Lic Class r l%r' D V
119 � /�¢whL123 locao
Contractor D to _ apt / /1 f m�
❑ a l �Y L U
am exempt under Sec W
Plan check fee W
B.BP.C. for this reason- �2 3 9 3 7 A
Date: Z
PERMIT ISSUING FEE $ # o • e e e $
Signature TOTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT ,) e - 2050
1 hereby affirm that I am exempt from the Contractor's License D e e e 2 a 5 Q 6
Law for the following reason (Section 70.31.5, Business and NAME
Professions Code):
El 1, as owner of the property, or my employees with
ADDRESS 0 �'2$—$6
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 se�.,1�. e41 ems /�
1 •V s .. L
El 1, as owner of the property; am exclusively contracting _ L ""t+
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS -
CONSTRUCTIONLENDINGAGENCY CITYa SSG��-es„-, TEL. NO
-1 hereby affirm that there is a construction lending agency for I D
the performance of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Ci, C.). M � "•' -
ADDRESS Sz`
Lender's Name ^ /
CITY G c C,c _ aC7 3 TEL. NIC.
Lender's Address —
STATE `/ LIC. 2`-�
I certify that I have read this application and state that the LICENSE NO. V3 12 J 61 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
upon the a -mention erty for insp coon purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Aill / .23/94
Signature o Appllcant or Agent Dot -