HomeMy Public PortalAbout8631 GARIBALDI AVE_Mechanical__ WORKEW COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self
Insure, or a certificate of Worker' Compenwtlgp Insurance, HEATING - VENTILATING - AIR. CONDITIONING
or a certlfled copy thereofc(Se3800, Lab. C.) LnSUrance 8(RfV I�/el)
Policy No , 1,71 5 p9ny Co. Df the West
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certlfled copy Is filed with the county building Inspec- FOR APPLICANT TO FILL IN BUILDING
tlon department. (PRINT OR TYPE ONLY) ADDRESS 86.31 E. Garibaldi Ave.
Data Applicant Royal Service LOCAIM Map: 37 F2
No. TYPE of APPLIANCE OR L-0UII'N4ENi FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST. Bartlett
(fhb section need not be completed If the work Involved by ABSORPTION UNIT, BTU DIMICT NO. PRoCE>s�BY
the permh Is for one hundred dollars ($100)or less.)
I ceriffy that In the performance of the work for which this AIR HM1DL NG UNIT, CFM
permit Is Issued, I shall not employ any person In any manner
to as to become subjectfo the No
Compensation Laws. BOILER, BTU APPROVALS DATE IN-34EtTOR'S SK'~TURE
Date Pit l ca n, COMPRESSOR, BTU Y� ROl1Gii
NOTICE TO I NT: If, dter ma nq Is Certfflcate of VEIMLAnoN SYSTEM FINAL -�
Exemption, you should biome subject to the Workers' _
Compensation provlsioru of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with -such provisions or this permit shall be
deemed revoked. FURNACE: FAU V GRAVfTY
LICENSED CONTRACTORS DECLARATION FLOOR BTU O
I hereby affirm that I am Ikensed under provisions of Chapter 9 HEADER: SU-SPENDED UNrT �T -TI
T
'(co-mmencing with Section 7000) of Division 3 of the Buslnea WALL 1
and Professlons Code,and my license is In full force and effect. d
317756 C-10 oil. A�C� ` —��hI L, Y S 7i1 u
License Number Llc. Class
of
Contractor Kenneth Yu Date 6/30/84 y `
❑ I am exempt under Sec.
Plan check fee a
iI!
B.BP.C. for this reason'
Dat �
PERMIT ISSUING FEE ; A2 c5b
e:
TOTAL FEE
Signature
V OWNER- UILDER DECLARATION PLAN CHEU APPLICANT
I hereby affirm that I am exempt from the Contractors 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 r 1-567A
wages as their sole compensation,will do the work and '0
the structure Is not Intended or offered for sale(Section Ta NO. � oo
TY
7044, Business and professions Code).
OWNER Q G O
❑ I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL
Ilan 7 , Business and Professions Code). ADDRE ` + o u o 3 Q 5 0
044
CONSTRUCTION LENDING AGENCY CITY
Cj TEL NO. ) 2 —8 ?
I hereby affirm+hat there Is a construction lending agency for '
the performance of the work for which this permit Is Issued r CONtRACTOR
(Sec. 3097, Civ. C-). -
Lenders Name ADDRESS
Ti NO.?o
Lender's Address 1
I certify that I have rood this application and state that the LICENSE NO. -3199-6CLASS C-.2 7 6 0
above Informatlon Is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and harebi authorize representati.ves of this County to enter
upon thea o-me tlonod property for Insp tion urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
519nature of ApplfooN or Agent