HomeMy Public PortalAbout9041 EMPEROR AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION
APPLICATION FOR PERMIT
J herp,�V_�ff(fm that I have a certificate of consent to self
Asifte, or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
CE-81
or a certified copy thereof (Sec. 3800, Lab. C.) C
� CE 818(REV. 10/81)
Policy No. Company
Certified copy is hereby furnished. COUNTY OVLOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILLtIN BUILDING
tion department. (PRINT OR TYPE ONLY) ADDRESS 9041 E. EMPEROR A
Date Applicant LOCALITY SAN GABRIEZ CA. 1
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
775
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS ST.IlVl3
COMPENSATION INSURANCE
(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.) /9OD 5 U
I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM -! t
permit is issued, I shall not employ any person in any manner BOILERBTU
so as to become subject to the Workers'Compensation LAWS: , APPROVALS DATENSP R'S SIGNATURE
C
Date //-/3^17Applicant- � COMPRESSOR, BTU V 6)() ROUGH .r!
NOTICE TO APPLICANT: If, after mak' th' Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER I-VALIDA416N
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU Y J,`)
LICENSED CONTRACTORS DECLARATION FLOOR TU ( (/
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.
O
License Number Lic. Class ,
Contractor Date O
❑ I am exempt under Sec. LU
Plan check fee IL
B.&P.C. for this reason' 4n
PERMIT ISSUING FEE $ j CJ �8 3 6.0 A �
Date:
TOT # o 0 0 0,0 8
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT FRANK J. NEVARIL, JR. �I - - 49.75
1 hereby affirm that I am exempt from.the Contractor's License
Low for the following reason (Section 7031.5, Business and NAME FRANK J. NEVARIL JR. a - 4 9.7 5 5
Professions Code):
I� I, as owner of the property, or my employees with ADDRESS 9041 E. EMPEROR AVE 1 1,r1 3 -'8 7
wages as their sole compensation,will do the work and CITY SAN GABRIEZ; TEL. NO. 285-9168
the structure is not intended or offered for sale(Section
7044, Business and Professions Code). OWNER FRANK J. NEVARIL, JR.
❑ I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS 9041 E. EMPEROR AVE.
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITYSA GABRIEZ 91775NO- 285-9168
I hereby affirm that there is a construction lending agency for ,
the performance of the work for which this permit is issued CONTRACTOR OWNER BUILDER
(Sec. 3097, Civ. C.).
ADDRESS 9041 E. EMPEROR
Lender's Name
-Lender's Address CITYSAN GABRIEZ TEL. NO.285_9168
STATE LIC.
I certify that 1 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
up o the above-m ntioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
oSignature,,p,VAPPIi ant or Agenf, Dote