HomeMy Public PortalAbout8606 GARIBALDI AVE_Mechanical__ WORKERS'COMPENSATION 1have cerci DECLARATION APPLICATION FOR PERMIT
I`he�qaff rm that I }gave a certificate of consent to self
"insure, or a certfficate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
i✓ or a certified copy thereof (Sec. 3800, Lab. G) . 764_3364C
CE-1318(REV. 10/81)
policy No.' Company
Certified copy Is hereby fumished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy Is filed with the county building Irspec-. FOR APPLICANT TO FILL IN BUILDING
tion department. (PRINT OR TYPE ONLY) ADDRESS Q
Date Applicant LOCAJTY
NO. TYPE OF APPLIANCE OR EQUIPME7NT FEE
CERTIFICATE OF EXF1 JMON.FROM WORKERS'. NEAREST
COMPENSATION INSURANCE CROSS ST
(This section need not be completed ff the work Invoheed by. ABSORPTION UNIT, BTU DMR C7 wo. PROCe
the permit Is for one hundred dollars (=100)or less.) /��
I certify that In the performance of the work for which this ALR FIANpJNG UNIT,CFM ✓(J
permit Is Issued, I shall not employ anyrson In any manner
to as to become subject a Work �Co pensation awe. BOILER BTU Vq�y D,Tp _� TuyE
�f b COMPRE , BTU ROUGH
Date v �Z y Ilcant SSOR
NOTICE TO APPLICANT: If, after making thA Certificate 'of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers' AWM 4
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATI
dh
with comply with such provisions or this permlt shall be
deemed revoked. F{1RDIACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter9 HEATER: UNIT /1 /S
(commencing with Section 7000) of Division 3 of the Business W� 0 V
and Professions Code,and my license Is In full force and effect. d
O
License Number Llc. Class ' V
Contractor Date O
❑ I am exempt under Sec. C'
Plan check fee
B.BP.C. for this reason
Date: PERMIT ISSUING FEE ;
TOTAL FEE
Signature
OWNER-BUILDER DECLARATION PIAN CHECK APPLK�NT
I hereby affirm that I am exempt from the Contractor's License , 6 a 3 A
NAME
Law for the following reason (Section 7031.5, Business and
Prof' Code): # • o o,o e 8
I, as owner of the property, or my employees with ADDS
wages as their sole compensation,will do the work and I ° - 2 (150
J
the structure Is not Intended or offered for sale(Section CITY C TEL ° ° • 2 Q 5 Q F'
7044, Business and Professions Code). ( 2 2 4 y$6
❑ I, as owner of the property, am excluslvely contracting
with licensed contractors to construct the project (Sec- MAIL
ADORESS p 4tion 7044, Business and Professions Code .
CONSTRUCTION LENbING AGEN qTyNO.
1 hereby affirm that there Is a construction lending ogency for poll.the performance of the work for which this pe'rrmitttIIssIssued CONTRACTOR, /
(Sec. 3097, Civ. C,). /t
ADDRESS
Lender's Name
CITY TEL NO.
Lenders Address
STATE / LIC
I certify that I have reod 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,
and hereby authorize representatives of this County to enter
v"
mentio
L"=- tft aboed o rty for Inspection pu � SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature Applkont or Agent Dat• -