HomeMy Public PortalAbout4924 FIESTA AVE_Mechanical__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PERMIT
F I Hm *,atereby affirat I have a certificate of consent to self
insure, bra certificate of Workers' Compensation Insurance, 76A364C HEATING - VENTILATING - AIR CONDITIONING
or a cerfified copy thereof (Sec.3800, 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
tion department. ADDRESS
(PRINT OR TYPE ONLY)
Date Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST. 1—d
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCES
the permit is for.one hundred dollars (:100)or less.)
AIR HANDLING UNIT, CFM
(.certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so ast too become subject to the Workers'Compensation Laws. BOILER, BTU
APPROVALS DATE N PE TOR'S SIGNAT RE
Dater✓�!i Applic COMPRESSOR, BTU ROUGH
\ NOTICE TO APPLI NT: If, after making this C ificat VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers' __.
Compensation provisions of the Labor Code, you must forth- o EVAPORATIVE COOLER VALIDATI N
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION I FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 SUSPENDED—UNIT—
'(commencing
USPENDEDUNIT'(commencing with Section 7000) of Division 3 of the Business HEATER: WALL
and Professions Code,and my license is in full force and effect.
Ap
License Number Lic. Class V
' BC
Contractor Date
0 I am exempt under Sec. �
Plan check fee
B.&P.C. for this reason PERMIT ISSUING FEE $ 5"v
Date:
Signature TOTAL FEE,�,
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License ,
Law for the following reason (Section 7031.5, Business and NAME t.
Professions Code):
I, as owner of the property, or my employees with ADDRESS 2
wages as their sole compensation',will do the work and
the structure is not intended or offered for sale(Section CITY �C C •T 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 -9 5 9 3.8 A
tion 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY TEL. NO. # 0 0 0 0 0 8
1 hereby affirm that there is a construction lending agency.for
the performance of the work for which this permit is issued CONTRACTOR
Poo. ( 0 0 2 Q 5 0
(Sec. s N ADDRESS Civ. C.). ^„ 0 0 - 2(1500'
CITY TEL.—NO.� '
Lender's Name �( 1, 14-8 6
Lender's Address
I certify that I have read this application and state that the STATE LIC.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
upor the above-mention property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
A /1 01/ / 4" �/d
Signature of Appli nt or Ag 1 -Date