HomeMy Public PortalAbout9941 GARIBALDI AVE_Mechanical__I
WORKERS'COMPENSATION DECLARATION S APPLICATION FOR PERMIT
I hereby affirm that I have a certtRcate of consent to self
Insure, or a certificate of Workers' (;ompensfrtion Insurance, �� HEATING VENTILATING - AIR CONDITIONING
Ifl ��MS&c. 3801), Lab. C 7 -618(REV. 10/81)
❑ ifled copy Is hereby furnished. COUNTY OF LOS ANGELES T"
/ BUILDING AND SAFETY
Ified copy Is filed with the county building I FOR APPLICANT TO FILL IN BUILDING (�
JJ"" rlan departmer�j. INT OR TYPE ONLY CESS "t
Il � )
Date Applican LOC1�LffY
NO. TYPE OF APPLIAfNCf OR Ci]IJIPMEM FEE
CERTIFICATE OF EXEMPTION FROM WOR S' NEAREST
COMPENSATION INSURANCE CROSS
(This section need not be completed if the work Imrohred by ABSORPTION UNIT, BTU DISTRICT No, PROCESS®BY R
tM permit is for one hundred dollars (;100)or less.)
I certify that In the performance of the work for which this AIR HANDLING UNIT, CFM 6 r/
permit Is Issued, I shall not employ anyn In any manner d
to as to become subject to the WorkersPCom pensation Laws, BOIL, BTU APPROVALS DATE a SPECTOR'S Sr—NATURE
Data AT p l i ca n t COMPRESSOR, BTU ROUGH
NOTICE TO APPLICANT: If, after making this Certiflcate of VENTILATION SYSTEM FINAL
Exemption, you should become subject'to the Workent`
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER /r�� VALIDATION
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hero by affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the BLmIness WALL
and Professions Code,a my I cense Is In full force and effect. O d
Llcense Number q,Ic. Clasr&1 V
OL
Contractor Date _ - Q
I am exempt under Sec.
Plan check fee an
B.BP.C. for this reason'
PERMIT ISSUING FEE $ (�
Data:
Signature TOTAL FEE o ;�.g 0 7;7 A
OWNER-BUILDER DECLARATION PLAIN CHEQC APPUCANT.
I hereby affirm that 1 am exempt from the Contractor's License , <? 0 0 o i' 1.
o o
Low for the following reason (Section 7031.5, Business and NAME
Profouloos Code): o'0 2 0
❑ I, as owner of the property, or my employees with ADDRESS
0 0 2()5()z
wages as their solo compensation,will do the work and ro
the structure Is not Intended or offered for sale(Section CITY NO.
7044, Business and Professlons Code). 0 9 cC 4
OWNER
❑ I, cLs owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- SIL <
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY OTy TEL 14�1_
I hereby affirm that there Is a construction lending agency for ,
the performance of the work for which this permit is Issued CONTRACTOR
(Sec. 3097, Civ. C.).
ADD ..
Lender's Name 641
CITY TEL _
Lendef's Address
STATE UC
I certify that I have read this appllcation and state that the INCENSE NO aAss
above Information Is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize repr ntatives of this County to enter
the abovo- o �p7� SEE REVERSE FOR EXPLANATORY.LANGUAGEnatuAlm -