HomeMy Public PortalAbout6214 ENCINITA AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION
PPL ICA TION FOR PERMIT
..I hereby affirm that I have a certificate of consent/to self P9 L P9 YCI Ir EHi
Insure, or a certificate of Workers' Compensation Insurance, 76A964C HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof(Sec. 3800, Lab. C.)
WTJ^$d -Ztiq�� �hQ `k ¢Y,„F7 CE-818(REV. 10/81)
Policy N rt 1 C hereby
COUNTY OF LOS ANGELES- BUILDING AND SAFETY
pony
Certified copy is hereby furnished.
®. Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING TT l A
tion de artment. � ADDRESS � 1I� �V 6✓~GJ L,�. 1 d ('�✓C.
�. J/ (PRINT OR TYPE ONLY)
Date a-Applican •`d�a� r - LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
' CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
ABSORPTION UNIT, BTU [71
(This section need not 6e completed if the work involved by
she permit is for,one hundred dollars ($100)or less.) AIR HANDLING UNIT, CFM p
I certify that in the performance of the work for which this � � PROCESSED B
p
permit is issued, I shall not employ any person in any manner u
so as to become subject to the Workers Compensation Laws. BOILER, BTU APPROVALS DATE ECTOR'S SIG ATURE
Date Applicant COMPRESSOR, BTU ROUGH i
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VAIL'IDATli
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU_GRAVITY
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. ' (w
d L
License Number Q 211 Lic. Class - D .O
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y. ) /'
Contractor 9301.4A m
s""o� vr.,cnl� Q/� /Q"� � � 0
❑ # e`ea e a 8 V
I am exempt oder Sec. W
Plan check fee d
B.BP.C. for this reason'
Date: ;( e - 2050 w
PERMIT ISSUING FEES Z
I
Signature TOTAL FEE e e 2 G'5 0 5'
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT o° C„ti('+"rw[.-f1 D 0 a 2 6-8 5
1 hereby affirm that I am exempt from The Contractor's License -
Low for the following reason (Section 7031.5, Business and NAME L;h.
Professions Code): -
❑ I, as owner of the property, or my employees,with ADDRESS 1 o Q- o s
wages as their sole compensation,will do the work and �i . '
the structure is not intended or offered for sale(Section CITY 1 15 d P--c- TEL. NO.
7044, Business and Professions Code). - -
OWNER
❑ I, as owner of the property, am exclusively contracting `"+'�•
with licensed contractors to construct the project (Sec- 'MAIL TT
tion 7044, Business and Professions Code). ADDRESS 4 2 G I-CZ t bv2.
CONSTRUCTION LENDING AGENCY CITY -T C ' TEL. NO.
I hereby affirm that there is a construction lending agency for /' 7-
the performance of the work for which this permit is issued CONTRACTOR Ay,..o (,�•,{� Co. s.wrr- D
(Sec 3097, Civ. C.). , r''^c*'
Lender's Name ADDRESS n
CITY 2...- TEL, NO.
Lender's Address .
certify that have read this application and state that The STATE LIC. [j
y pp LICENSE NO. Q _ �� CLASS Q
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-mentione property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE _
Signature of Applicant or Agent Dote