HomeMy Public PortalAbout8633 GARIBALDI AVE_Mechanical__ WORKERS'
COMPENSATION
ffisrDECLARATDECLARATIONAPPLICATION FOR P E RM I T
I hereby arm that I have a certificate of coaent to pelf
Insure,.or a cl lcar pf'�lorkers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
,pr ci_ca'Oiecl copy tnerea (Sec. 3800, Lab. C.) 20-0046
2Q-0Q46 DPW 9/88 '
Pb11cy No Company
Certified copy Is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
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Certified copy Is filed with the county building Inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. (PRINT 863,T '6 1L V
(PRINT OR TYPE ONLY)
Data Applicant- LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTIONFROM WORKERS' NEARESTA,� c
COMPENSATION I NSU I[11 V CE CROSS ST. /`r 1 7
(This section need not be completed H the work Imohmd by ABSORPTfON UNIT, BTU DMM)CT NO. B.
the permM Is for ons hundred dollars (;100) or less.)
I certify that In the performance of the work for which this AIR I WiJDLING UNIT, CFM
permit 14 Issued, I shall not employ any person In any manner BOILER BTU
so as to become subject to the Workers Compensation Laws. APPRCAV LS DATE I 3KR4ATURE
Date Applicant COMPRESSOR' BTU ROUGH �
NOTICE TO APPLICANT: If, after making'this Certtflcate of VENTILATION SYSTEM FINAL
Exemption, you should become subleat to the Workers
Compensatlon provisions of the Labor Code, you must forth- EVAPORATIVE COOLE32 IDATION
with comply with such provisions or this permit shall be deem-
ed revoked. FURNACE: FAU GRAVITY
UCENSM CONTRACTORS DECLARATION FLOOR TU �f
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDIED UNIT-
(commencing with Section 700x)of Division 3 of the Buslneu WALL
and Professions Code,and my license Is In full force-and effed.
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License Number I Ic. Clau T , O
U
Contractor Date e I 0
❑ I am exempt under Sec. 0
Plan check fee w
B.BP.0 for this reason PERMIT ISSUING FEE $ IA
a
Date: 0E. Z
TOTAL FEE
Signature
.00
OWNER-BUILDER DECLARATION PLAN CHECY APPU ANT
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' A
wages as their sole compensation,will do the work and A'CT•r
the structure Is not Intended-or offered for sale(Section CTfY TEL �' 7 17 c '
r
70", Busineand Professlons Code). OWNER
37+J .cJ
ss
I, as owner of the property, am exclusively contracting 1 ITEMS
with licensed contractors to construct the project (Sec- MAIL
tion 70", Business and Professions Code). ADDRESS TOTAL 55 - 00
CONSTRUCTION LENDING AGBJCY CITY TEL 1`40. -eW t-CA614 55.00
1 hereby affirm that there Is a construction lending agency for ,
the performance of the work for which this permit Is Issued OONTRAC'TeR CIME w
(Sec 3097, Ov. C)_
ADDRESS
Lenders Name 7 ��y/p.
CITY TEL NO. LrL70.-.1D--_�W I fw/i�n�7 LI
Lender's Address STATE LI C_ - 1 t I 1 rf I lU w
I certify that I have read this application and state that the USE 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
upon the above-mentloned property for Inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
272W-am 64
Slgrgture of Applt=t or Date I �s