HomeMy Public PortalAbout10119 GREEN ST_Mechanical__ --� r-,-
VKORKERS'COMPENSATION DECLARATION
I hert�by affirm that I have a certificate of tarsen, to :elf APPLICATION .FOR PEWIT
Insure,or a certificate of Wore�rr}} Corypensation Insurance, 76n. c HEATING - VENTILATING. - AIR CONDITIONING
k pr g cerpfloA ropy fAerbof (mac. 3800, Lab. C.)
CE-el B(Rev..10/81)
Pollc`} +. Company COUNTY OF LOS ANGELES BLILDING AND SAFETY
❑ rtifled copy is hereby furnished.
❑ Certtffed copy Is filed with the county building Inspec- FOR APPLICANT TO FILL IN BUILDRJG
tlon department. d
(PRINT OR TYPE ONLY)
Date Applicant LOCALITY 7—e, C t
NO. TYPE OF APPLIANCE OR EW IPMBJT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' I I
NEAREST
COMPENSATION INSURANCE CROSS ST. B�d G,OGv!/`/
(This section need not be completed if the work IrtvoNed by ABSORPTK>N UNIT, BTU DMT00 NO.
the permit 4 for one hundred dollars (=100)or less.) L
I oertlfy.that In the performance of the work for which this 7
Amit Is lased, I shall not employ any person In any manner r
to become sublect to the Workenompensation Laws. BOILER, BTU AP990VALS DATE N&Kp yxarax
Date��- 21 r V& Anpllcnnt��� BTU ROIYGH
NOTICE TO APPLICANT: If, after making this 64Kfficarta of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATNE COOLER , VALIDA
with comply with such provisions or this permit shall be
deemed revoked. 1 FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION r FLOOR BTU t70
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER-. SUSPENDED IINIT
'(commencing with Section 7000) of Division 3 of the Business WALL
Y
and Professlons Code,and my license Is In full force and effect.
CL
0
License Number Llc. Class f , V
OL
Contractor Date W
❑ I am exempt under Sec.
Plan check fee
h
B.BP.C. for this reason Z
PERMIT ISSUING FEE $
Date:
TOTAL FEE
Signature
OWNER-BUILDER DECLARATION PLAN CHEC)c APPLICANT
I hereby affirm that I am exempt from the Contractors License
Law for the following reason (Section 7031.5, Business and NAME
ProfessI ns Code):
as owner of the property, or my employees with
wageCITYTEL tNO.s as their sole compensation,will do the work and 7T3 �ZQ� .
the structure Is not Intended or offered for sale(Section TG I
7044, Business and Professlons Code).
❑ I, as owner of the property, am exclusively contracting `S' 6 0 0.5-A
with licensed contractor to construct the project (Sec- AbDRMAIESS "r-i�
tion 704 , Business and Professions Code). #b o o s 0 8
CTI ,
CONSTRUON LENDING AGENCY CITY TELNO.
_
I hereby affirm that there Is a construction lending agency for ' I • ° 3&Z 0
the performance of the work for which this permit Is Issued CONTRACTOR
(Sec. 3097, Civ. C.). o 0 0 3 6.2 0 6
ADDRESS
Lenders Name 1 .1,21 -86
CITY TEL NO.
Lenders Address
STATE uc
I certify that I have rood this oppllcotion and state that the LICENSE NO. CLASS .
above Information Is correct. I agree to comply with all County
ordinances and State laws relating to bulMing construction,
id hereby authorize representatives of this County to enter
/upon the above-mentionedproperty for propefor Inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
✓ // •21 . 1-6
Signature of Applicant or gar,,
Date