HomeMy Public PortalAbout9409 GARIBALDI AVE_Mechanical__ 'T
WORKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby aff rm-that I have a certificate of consent to %elf"
Insure, or a certlficate of Workers' Compensatrbn Insurance, ' HEATING - VENTILATING - AIR CONDITIONING
cr a certified copy thereof (Set. 3800, Lab. C.) 7M-16C
CE-918(REV. 10/81) Q' G
acy No. Company
Certified copy Is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAF
❑ Certified copy Is filed with the county building Inspec- FOR APPLICANT TO FILL IN BUILDING
A55 �
tion department. L J� /� (PRINT OR TYPE ONLY)
Date App l l ca n �+ LOCALrrY
TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE Of EXEMPTION FROM WORKERS' T
COMPENSATION INSURANCE CRO6S SF.
(This section need not be completed If the work Involved by ABSORPTION UNIT, BTU DISTRICT NO. PROS BY
the permtt Is for one hundred dollars (;100)or less.)
I certify that In the performance of the work for which this AIR HANDLING UNIT, CFM C n
permit Is Issued, I shall not employ anyn In any manner
so os to become subject to the Work" ampenaptlon Laws. BOILER, BTU ,.,PROv,ub n sualcTOR'SSK*JATURE
Date Applicant COMPRESSOR, BTU ROOGFi
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Work"
Compensation provisions of the Labor Code, you must forth- EVAPORATTVE COOLER VALIDATION
with comply with such provisions or this Permit shall be
deemed revoked. FURNACE: FAU GRAV rY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am Ilcersed under provisions of Chapter 9 HEAD: SUSPEN9� UNIT J
'(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code,and my license Is In full force and effect.
License Number Llc. Class
' OC
Contractor Date GO
❑ I am exempt under Sec.
Plan check fee a
V/
B.BP.C. for this reason
Date: PERMIT ISSUING FEE ;
Signature TOTAL FEE _
OWNER-BUILDER DECLARATION RAN CHECK 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 5 A
9 3 a
wages as their sole compensation,will do the work and CITY. TEL NO #'o o o o'o 8
the structure Is not Intended or offered for sale(Section
7044, Business and Professlons Code).erty2Io - 20,5.0
01V � ,
❑ I, as owner of the prop , am exclusively contracting OWNER {
with licensed contractors to construct the project (Sec- MAIL ADDRESS 0 0,0 2 0.5 Tu
tion 7044, Business and Professions Codde).
CONSTRUCTION LENDING AGENCY CITY TEL NO. 0,125—8 3
I hereby afflrm that there Is a construction lending agency for Pool
performance of the work for which this permit Is Issued CONTRACTOR
(Sec. 3097, Clv. C-).
Lenders Name
CITY TFL NO.
Lenders Address
STATE UG
I certify that I have read this application and state that the UCENSE NO. CLASS
above Information Is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
d hereby authorize representatives of this County to enter
n the gnaaLanZlled or Inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
_ r
5lture of Appllcant or Agent I• .