HomeMy Public PortalAbout6161 ENCINITA AVE_Mechanical__ DEC
TION
YJOR"IffRS' -1COMPENSATION cafe of cons. APPLICATION
PPLIC TION FOR PERMIT s_i^.hereby afji", thai i have a certificate of consent to self ,�/�%�� P'i P9 0 Ltl Ir IG Y'IFV� 0
• Insure, or a certificate of Workers' Compensation Insurance, ]6A364C HEATING VENTILATING - AIR CONDITIONING
or a Fortified copy thereof (Sec. 3800, Lab. C.) CE-818(REV. 10/8I) -
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 ('
ti n dep'artr�eyp L ' (PRINT OR TYPE ONLY) ADDRESS I_
Dote ^� J Applicant 6`U �� LOCALITY (e
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' - NEAREST
COMPENSATION INSURANCE �O Ol9 QO CROSSST n
(This section need not be completed if the work involved by ABSORPTION UNIT, BTu DISTRICT NO. PROCESS v
the permit is for one hundred dollars ($100)or less.) AIR HANDLING UNIT, CFM O
_I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. BOILER, BTU �J /� APPROVALS )ATE SP TOR'S SIGNA E
COMPRESSOR, BTU /�/_OQ0 O Oa+ ROUGH ,i
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of _ VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers' J
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALI DATI N
wilh comply with such provisions or this permit shall be
deemed revoked. FURNACE: -QRAgITX
LICENSED CONTRACTORS DECLARATION FLOOR BTU
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
License NumberI (_ I c. Class _ D V
cc
Contractor T 'e -` one I2 �.� 0 6 4 7-A O
❑ ~
I am exempt under Sec. 8 V
W
Plan check fee
B.BP.C. for'this reason' ) is * 3(150
N
PERMIT ISSUING FEES e e e 3 0.5 06
Date: 2
Signature TOTAL FEE 0 9.4 2r':.8 8
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
hereby affirm that I am exempt from the Contractor's License D i
Law for the following reason (Section 7031.5, Business and 'NAME -n; f
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 Cliv en Crn
TEL. NO.
7044, Business and Professions Code). 1 -
OWNER J l
❑ I, as owner of the property, am exclusively contracting v
with licensed contractors to construct the project (Sec. MAIL - -
tion 7044, Business and Professions Code). ADDRESS ,
CONSTRUCTION LENDING AGENCYCITY l TEL. NO, '
I hereby affirm that there is a construction lending agency for D
the performance of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C-). - ..
ADDRESS GLS... ,
Lender's Name n �f
.CITY uG� TEL. NO.
Lender's Address
[ITAI.C.
I certify that I have read this application Dnd 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 -
upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signator.of Applicam or Agent Date - -