HomeMy Public PortalAbout10802 GRAND AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION CE 8818C(2-80) APPLICATION FOP PER T
i I hereby affirm that I have or certificate of consent to self
insure, or a Certificate of Workers'Cgmpensation Insurance,o•r HEATING-VENTILATING-AIR CONDITIONING
■certified copy thereof(Sec. 3800,Lab. C.)
Policy No. Company f ,
Certified copy V hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
D Certlfled copy is filed with the county buildinginspection /J
department. FOR APPLICANT TO FILL IN ADIDRESS h� D
Date Applicant, (PRINT OR TYPE ONLY)
LOCALIT
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE,ORIEQUIPMENT FEE
COMPENSATION INSURANCE NEAREST /
(This section nbed not be completed if the Rork bmtred ABSORPTION UNIT, BTU CROSS ST.,c�'/,� .
by the permit is for one hundred do✓m ($100) oc less.) DISTRICT NO. PROCESS BY
I certify that In the performance pf the work for which this AIR HANDLING UNIT CFM
permit Is issued, I shall not a any person In my mar}ner • Q
so as to begome aub}ect t e W rkers' ompegsatlon Lawn. BOILER BTU CrWr±7
APPROVALS DATE INSFECTOR-8SIGN6TURE
Data pPllcan COMPRESSOR BTU a
�i O lJ G H
NOTICE TO APPLICANT If iter making Certlticate of Z
Exemption, you should oma .&ubJect the Workers'. VENYILATION SYSTEM FINAL
Compensation provlslbn& of the Labor Cod you must forth-
with comply with such provisions.or this permit &hall be EVAPORATIVE COOLER VALIDATION
deemed revoked.
FURNACE: FAUT GRAVITY
LICENSED CONTRACTORS DECLARATION FLOOR: BTU
M I hereby afllrrh t6t'l am licented under provisions of Chapter HEATER: WIWILNDED UNIT
( 9 (commencing with Section 7000) of Division 3 of the' Buai-
nese and Profnatons Code; and my license is in fdli force and 20
effect.
License Number Lic.Class
Contractor Data
Iam exempt from the'liconfing requirements as I am a
licensed architect or a rdtistered profetsiohal engineer Plan check fee 26%of above.
acting in.my professional capacity (Section 7051, Bus-
' Ines&and Professions Code). PERMIT ISSUING FEE $
Lic,or Reg.No. Date TOTAL FEE
HOME OWNER-BUILDER DECLARATION PLAN..CHECK,APPLICANT
I hereby affirm that I am exempt from- the Contractor's NAME
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): ADD-R ESS
1, as owner of the property, will do the work and the ;F0 1 •7 8 A
structure is not Intended. or offered for sale (Section CITY TEL. NO.
7044, Business and.Professlona Code). � *;a.0
fier of the ' OWNER ! #; �'�
❑ 1, as ow
property, am exclusively contracting qf ti
with licensed contractors -to construct the project MAIL ,2,• • 1 7,00
(Section 7044, Business and Professions Coda). ADDRESS
CITY d �G TEL. NO. a,a•'e � 7 a0
CONSTRUCTION LENDING AGEtqCY /f
I hereby affb-m.that there L a construction lending agency CONTRALTO Q -8
for the performance of the work for which this permit Is
issued Sec. 3097,CiV.C.). µ
Lender s Name ADDRESS
Lender's Address CITY i7 TEL _R
I certify that I have read this application and state that the STATE CLC.
above informaflon Is correct. I agree to comply with all CountyNO, SS
ordinances and State laws regulating Hosting, Ventilating and
ndittoning, and hereby authorize representatives of this SEE REVERSE FOR EXPLANATORY LlkNGUAGE
unt to a upon the -abovo-mentloned property for
Lns n p -
JA
u e e Date