HomeMy Public PortalAbout9147 EMPEROR AVE_Mechanical__ IKERS'COMPENSATION DECLARATION L'1 .01
-that I have a certificate of consent to self APPLICATION FOR PERMIT
insure, or certificate of Nvor�Cer;' Compensation Insurance, 76A364C HEATING - VENTILATING - AIR CONDITIONING /3//(
or a certified copy thereof..(Sec`. 'M60, Lab: C.)
CE-818(REV. 10/81)
Policy No. Company
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING 4 G/l
tion department. (PRINT OR TYPE ONLY) ADDRESS
Date Applicant LOCALITY T
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
(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.) Q 8
1 certify that in the performance of the war for_which this AIR HANDLING UNIT, CFM
permit is issued, I shall not employ any pers in a manner BOILER, BTU
so as To become Ru bb' ct to the Wor rs'C pe tion Laws. [ d1 APPROVALS DATE INSP R'S SIGNATUR
Date V ' Applica CoMPRESSOR, BTU v QvO o Bw, ROUGH
NOTICE TO A ICANT: If, a making This ,Ceicate of VENTILATION SYSTEM FINAL J
Exemption, you should become subject to th' Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATI
with .comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU RI Y OCIO
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED UNIT '
(commencing with Section 7000) of Division 3 of the Business HEATER: WALL'
and Professions Code, and my license is in full force and effect. o
el
e � S u �y oil e s S
License Number 1/735'2J Lic. Class `—210 , 0
/�A 111I ��^^ r UNA p1
ContractolLlr' mgt Date 9'8 6.6 A
I am exempt under Sec.' #.o o'o�o o 8 &U
Plan check fee IL
B.BP.C. for this reason PERMIT ISSUING FEE $ L9 `1 '0 0.3 11,0 0
Date:
Signature TOTAL FEE �� .o.0 0'3 IL 0 6
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT O 6 1 3v"-8 8
I hereby affirm that I am exempt from the Contractor's License ,
Law for the following reason (Section 7031.5, Business and NAME
Professions Code):
❑ I, as owner of the property, or my employees with ADDRESS
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). . .
OWNERV096po 101
❑ I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL din/�
tion 7044, Business and Professions Code). ADDRESS 9 �m ic.o
CONSTRUCTION LENDING AGENCY CITY *% /� ��/ /v. TEL. NO.
I hereby affirm that there is a construction lending agency forll
the performance of the work for which this permit is issued CONTRACTOR / A ] Qr!
(Sec. 3097, Civ. C.). CA F� 0 U• ATO:-
ADDRESS ��
Lender's Name
CITY. T
Lender's Address
STATE LTC.
I certify that I have read this application and state that the LICENSE NO. O CLASS e,.
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
ad h by aut rize representatives of this County to enter
u n abov - entioned property for insp cti0 pur ses. SEE REVERSE FOR EXPLANATORY LANGUAGE
_ 6 t3 8"�
scant or ent