HomeMy Public PortalAbout5004 FIESTA AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
�;'`! hereby affirm that I have a certificate of consent To self
ins6r-C,'or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec. 3800, Lab. C.) 76A364C
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 BUILDING7`4
tion department. (PRINT OR TYPE ONLY) ADDRESS ! �/
Date Applicant NO. TYPE OF APPLIANCE OR EQUIPMENT. "FEE LOCALITY
VVV l
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST. �
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY
the permit is for one hundred dollars ($100)or less.) �]v
AIR HANDLING UNIT, CFM
I certify that in the performance of the work for which this s.
permit is issued, I shall not employ' ny person in any manner BOILER, BTU
so as to becom subject to the Woers'CompensaYJ
Zws. APPROVALS DATE !NSP TO S SIGNATURE
r ^
Dare Applica COMPRESSOR, BTU ROUGH A
NOTIC TO PPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL � 3• f.
Exemption, you should become subject to the Workers' /
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATI
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 /1
'(commencing with Section 7000) of Division 3 of the Business WALL (f
and Professions Code,and my license is in full force and effect.
�226,4A ,O
License Number Lic. Class , V
9.o o e o 8 .09
Contractor Date O
H
F1I am exempt under Sec. ( e e 3 Q 5 0 d
Plan check fee
B.&P.C. for this reason H
o e e 3 Q 5 0 v z
PERMIT ISSUING FEE $
Date:
Signature TOTAL FEE 0 'Q &l 4-85
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT 100,
I hereby affirm that I am exempt from the Contractor's License ,
Law for the following reason (Section 7031.5, Business and NAME
Professions Code):
❑ I, as owner of the property, or my employees with ADDRESS
U1 V
wage's as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section CITY 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- MA
tion 7044, Business and Professions Code). ADDRESS
CONSTRUCTION LENDING AGENCY CITY TEL. NO. �`,2(�,,
I hereby affirm that there is a construction lending agency for e97 V ,
the performance o he wor or which this permit is issued CONTRACTOR /
(Sec. 3097, Civ. C
ADDRESS
Lender's Na
CITY TEL. NO.
Lender' ddress
STATE LIC.
I certify that I have read this application and 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,
a hereby authorize representatives of this County to enter
n th above-me ned pro ty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signature of Applicant or Agent Date