HomeMy Public PortalAbout6243 ENCINITA AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION
®P0 IC A TION FOR PERMIT
.I"hereby'6ffirm that I hove a certificate of consent to self i9r L i'Y Erl AVE
insure, or a tertificaler of Workers'Compensation Insurance, 76A364C - HEATING - VENTILATING - AIR CONDITIONING
or a certified copy Thereof (Sec. 3800, Lab. C.)
CE-818(REV. 10/8I)
1:1 Certified copy is hereby furnished.
Company COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDINGZL �nIC�� .I ' 4-A_
tion department.
(PRINT OR TYPE ONLY) ADDRESS A 1
Date ' Applicant LOCALITY x_f4j�L- � C) 'r--y
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
(This:action need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY
the permit Is for one hundred dollars ($ 00)or less.) AIR HANDLING UNIT, CFM
I certify that.in the performance a ork for which this
permit is issued, I shall not employ y p Isom in any manner BOILER-BTU
so as to b cam subject to the W k rs' om,peryF!otion La ,
Laws. APPROVALS DATE INSP 'S SIGNATURE
Date
16
J Applicant !�'^-s�'"'"� COMPRESSOR, BTU 36 rO""' C ROUGH Q.-
NOTICE O PLICANT: If, afte eking 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 VALIDATION
With comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU G1tAYJTY„�� D D
LICENSED CONTRACTORS DECLARATION FLOOR TU ��C�(.CXJ
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT_ r
'(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code,and my license is in full force and effect. Ou r) yq.� y
!iG I 7 O
License Number LIc. Class—
Contractor
lass Contractor Date O
V
❑ 1 am exempt under Sec _ Iu
Plan check fee H
B.SP .C. for chi`s reason' PERMIT ISSUING FEE $ 2
Dote:-
Signature TOTAL FEE QD
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT #tY Y e
I hereby affirm that I am exempt from the Contractor's License 1:0 e 4 x O,O
/
Law for the following reason (Section 7031.5, Business and NAME SE t D
Professions Code): - Al �( ee a ny r
I, as owner of the property, or my employees with
u
ADDRESS
El l NGW ry-h—
wages as their sole compensation, will do the work and .7- � / rr I �-(�
the structure is not intended or offered for sole(Section CITY �E CCJJ VCS , / TEL. NO-3,09-03&
7044, Business and Professions Code).
OWNER
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY " 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
Lender's Name
CITY TEL. NO.
Lender's Address
STATE LIC.
I certify at I have read this application and state that the 1 LICENSE NO. CLASS
Avyinf4mation is correct. I agree to comply with all County
ord e"bontioned
s relating to building construction,
a heesentatives of thi Coun y to enter -
u o tproperty fo?6s�c,_ Pur uses. SEE REVERSE FOR EXPLANATORY LANGUAGE -
Signature of Applicant or Agent. CU 1,