HomeMy Public PortalAbout10671 FAIRVIEW AVE_Mechanical__ reWORKERS COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers Compensation Insurance, - HEATING - VENTILATING - AIR CONDITIONING
or o'certified co y there �of (Sec 3800 Lab C ) 76A364C r
CE 818(REV 10/81)
Poli_ f�lr 17'2r9Pony 6 4-7L
® Certified copy is hereby furnished ' . I COUNTY-OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN _ BUILDING ��46
Tion dADDRESS epartment (PRINT OR TYPE ONLY)
+Dare �' 116– e� Apphcan NO, TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY
` CERTIFICATE OF EXEMPTI N FROM WORKERS' _ NEAREST
COMPENSATION INSURANCE z CROSS ST
(This section need not be completed if the work involved by ABSORPTION UNIT BTU T DISTRICT NO v V PROCESSED BY1
the'permit is for one hundred dollars (;100)or less )
I certify that in the performance of the AIR HANDLING UNIT CFM'work for which This _ , ,
permit is issued,-I shall riot employ any person in any manner
so as to become subject to the Workers Compensation Laws BOILER BTU APPROVALS DATE N5 OR SIGNATURE
Date Applicant ' OMPRESSOR BTU (/(/ ROUGH
NOTICE TO APPLICANT If, after`making this Certificate of VENTILATION SYSTEM ° FINAL c
Exemption you `should become, subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDAT ON
with comply with such provisions or this permit shall be
deemed revoked FURNACE FAU G VITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU (�
I hereby affirm that I am licensed under provisions of Chapter 9HEATER f 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 ! – r
License NumberjAt42�5 b 74 Lic Class I—P F
Contract A ~ Date – _ O
❑ - a
I am exempt under Sec � W
PIcn check-fee - H
B"&P C for this reason a 1
PERMIT ISSUING FEE $- _
_ Date ,
Signature TOTAL FEE ®'
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT r
I hereby affirm that I am exempt from the Contractor s License ® L
Law for the following reason (Section 7031 5, Business and NAM Cd,i_T
Professions Code) r
❑ I as owner of thero eri RES '�
p p y,>or my employees with _ L i f,
wages as their sole compensation,will do the work and >;r^�--
the structure is not intended or offered for sale(Section CITY TEL _ e ��
7044 Business and Professions Code) OWNER {_WL�
❑ I as owner of the property, am exclusively contracting o
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 It Jr eleoe-11Li ,,
the performance of-the work for which this permit is Issued CONTRACTOR c a o =L
(Sec 3097, Civ C )
ADDRESS
Lender s Name
CITYI _ TEL N A
Lender s Address �-�-+ �" �
STATE J sy LIC Q' 1
I certify that I have read this application and state that the LICENSE ` CLASS
above information is correct I agree to comply with all County
ordinances and State laws relating to building construction `w W
and hereby authorize presentatives of this County to enter
U the above e on property for inspection purposes _ SEE REVERSE FOR EXPLANATORY LANGUAGE .
1
Signature of Applicant or Agent Date