HomeMy Public PortalAbout9835 GARIBALDI AVE_Mechanical__ WORKERS'COMPENSATION DEC ARAI�o(J APPLICATION .FOR P E RM I T
I hereby affirm that I have a certtflcate of consent to self ,
Insure, or a certificate of Workers' Compersatlon'Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec. 3800, Lab. C.) CE-818
Policy No. Company
Certified copy Is hereby furnished. COUNTY OF LOS ANGELES �� BUILDING AND SAFETY
r
❑ Certified copy Is filed with the county building Inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. (PRINT OR TYPE ONLY)
`
DRESS
Date r? Applicant NO.
O. TYPE Of APPLfJ(� C�
IAOR LIIPMJ7JT FEE LOCALITY
CERTIFICATE OF D(EMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS 5T. N�s
pRp�
(This section need not be completed H the work Irrvohred by ABSORPTION UNIT, BTU DC5TRiCT NO
the permit ts for one hundred dollars (;100)or less.) p�
I certify that In the performance of the work for which this AIR FIANDUtJG UNIT, CFM iU
permit Is Issued, I shall not employ
�Cany rson In any manner
so as to become subject to the Workers
,oJmpensatlon Laws. BOILER, BTU APPROVus -ATE IN3PEcmR'3 SK~TURE
_ CO&WRESSOR, BTU R0 X30' •�
Date -2_ pllcant
NOTICE ft
TO APPLICANT: If, after making this ertlficate of VENTILATION SYSTEM FINALI�� .�
Exemption, you should become subject to the Workers'
Compensation provlslons of the Labor Code, you mutt forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY T
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER- SUSPF_ND D UNIT
(commencing with Sectlon 7000) of Division 3 of the Business WALL
and Professions Code,and my license Is in full force and effect. d
O
License Number Llc. Class , V
OL
Contractor Data O
❑ I am exempt under Sec.
Plan check fee a
8.8P.C. for this reason PERMIT ISSUING FEE $ Q Q
Date:
Signature TOTAL FEE
OWNER-BUILDER DECLARATION PLAN CYIECx APRICANT
I hereby affirm that I am exempt from the Contractors License
Law for the following reason (Section 7031.5, Business and NAME , ` 7 7 g 6
Professions Code):
1, as owner of the property, or my employees with ADDRESS `0 0 0 o e 8
t ,
wages as their tole compensation,will do the work and j� TELp 2�vf
the structure Is not Intended or offered for sale(Section 471 l D 7 ' ` ;1'0)o > Q„rj
70.4", Business and Professions Code).
C;iNtJER v
❑ 1, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS ) G 2 2—8 3
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY TEL. NO.
I hereby affirm that there Is a construction lending agency for ,
the performance of the work for which this permit Is Issued 03KI-RACTOR
(Sec. 3097, Cly. C_).
ADDRESS .
Lender's Name
CITY T9. NO.
Lender's Address
I certify that I have read this application and state that the ULICEN LIC
CBJSE NO. (]ASS
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
on thea ve en ed property for Inspection purposes. SEE.REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date -
t