HomeMy Public PortalAbout9068 EMPEROR AVE_Mechanical__ • r 'WORKERS'COMPENSATION DECLARATION
K
V i"reby affrrm that I have a certificateiof consent to self APPLICATION FOR PERMIT
Insure, or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a'ertifiCE-81 ed copy thereof (Sec 3800, Lab C ) C
CE 818(REV 10/81)
L licy No Company
Certified copy Is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy Is filed with the co ty building inspec- - FOR APPLICANT TO FILL IN BUILDING Fp4iC &M
tion d part ent (PRINT OR TYPE ONLY) ADDRESS o z
l
Date Appl Icam LOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM W KERS' NEAREST �fwK
COMPENSATION INSURANCE CROSS ST /�"V Cr
(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`) t r�Dd _L_60
I certify that In the performance of the work for,which this ` AIR HANDLING UNIT, CFM
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 IN EC *SIGNATRE
Date Applicant COMPRESSOR, BTU �/ ROUGH
NOTICE TO APPLICANT If, after making this Certificate of VENTILATION SYSTEM FINAL fir_
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 FURNACE FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that'l am licensed under provisions of Chapter 9 HEATER SUSPENDED—UNIT—
(commencing
USPENDEDUNIT(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code,and m license Is In full force and effect
9116
,License NumberLlc Class u
T� JJ �N ► C9
Contractor CA4 k T A) �& " IP,cit. O
t—
u
I am exempt under Sec U
Plan check fee
H
B &P C for this reason PERMIT ISSUING FEE $ z
Date r �
TOTAL FEE
Signature
OWNER-BUILDER DE&AATION PLAN CHECK APPLICANT 9 0 2 2 5 A
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031 5, Business and NAME 57tA j # o o,o,o 0 8
Professions Code)
❑ I, as owner of the property, or my employees with ADDRESS ((06r, V �77?i7R, ) ° ° 4 a 0 0
wages as their sole compensation,will do the work and 4 O 0
the structure Is not Intended or offered for sale(Section CITY L� c�,c•r TEL NO o 0 0
7044, Business and Professions Code) ,�/ 1
�� 9—
❑ I, as owner of the property, am exclusively contracting OWNER 07, 1,
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code) ADDRESS
CONSTRUCTION LENDING AGENCY CITYL� 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 s tL1�
(Sec 3097, Civ C ) -
ADDRESS 10
Lender's Name ,,Aft
Lender's Address CITY �p�,/l' TEL NO ,Jl
I certifythat I have read this application and state that the _ STATE ~v — CL
pp LICENSE NO �� CLASS -
above Information is correct I agree to comply with all County
ordinances and State laws relating to building construction,
and hereb authorize representatives of this County to enter
upon th ove-mentioned, erty for Inspection Zuoses SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of App nt or Agent Date '