HomeMy Public PortalAbout6141 HART AVE_Mechanical__ IYWORKERS'COMPENSATION DECLARATION A P P U C/° M N F Oo Q PERM Y
"�,vaffArm„that I have a certificate of consent to self '
'insul�”, dr a certificate of Workers,.Compensation Insurance, HEATING - VENTILATING AIR CONDITIONING
-8r a certified copy thereof (Sec. 3800, Lab. C.) CE-81 C
CE-618(REV. 10/81)
Policy No. Company
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Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING ARID SAFETY
. Certified copy is filed with the county building inspec- FOR-APPLICANT TO FILL IN BUILDING
tioh department. (PRINT OR TYPE ONLY) . ADDRESS
Date Applicant LOCALITY'-�—'(�^+
NO. TYPE OF APPLIANCE OR EQUIPMENT. FEE _C V "
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
CROSS ST. CJ1+7a,1
COMPENSATION INSURANCE
(This section need not be completed if the work.involved by ABSORPTION UNIT,'BTU DISTRICT NO. PROCESSED BY
the permit is for one hundred dollars ($100)or less.)
AIR HANDLING UNIT, CFM 0J(
I certify that in the performance of the work for which this 510g"
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permit is issued, I shall not employ any person in any manner BOILER, BTU
so as to becoo^me subject to the Workers'Com enSatlOn Laws. APPROVALS DATE INSPECT 'S SIGNATURE
ka-
Date r- I J��`� Applicant 4 COMPRESSOR,'BTU ROUGH
NOTICE TO APPLICANT: If, 'after making this Certifica e of VENTILATION SYSTEM FINAL ,
Exemption, you should become subject to the Worcers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDAT N
with comply with such provisions or this permit.sholl be
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS.DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions"of Chapter 9 HEATER:' SUSPENDED UNIT � /f
'(commencing with Section 7000) of Division 3 of the Business WALL (J
and Professions Code,and my.license is in full force and effect. a
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License Number Lic. Class—
Contractor
lass ContractorDate X 2 4(L 9 A O
°.
I am exempt under Seca {# o o.o o 8 w
Plan checkleeCL
B.&P.C. for this reason H
° ° 2 0,5 0 Z
� - - PERMIT ISSUING-FEE $ (f S� I
Date:
Signature TOTAL FEE
OWNER-BUILDER DECLARATION ' PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business'and NAME �� D
Professions Code):
r
I, as owner.of the property, or my employees with ADDRESS -
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale(Section CITY _��, TEL. NO. �_
7044, Business and Professions Code).. OWNER `
❑ I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions-Code).
ADDRESS
CONSTRUCTION.LENDING AGENCY CITY TEL.'NO. '
I hereby affirm that there is a construction lending agency for. D
the performance of the work for which this permit is issued CONTRACTOR
(Sec. 3097, Civ. C.): �
ADDRESS
Lender.'s Name
` .. CITY TEL. NO.
Lender's Address r
STATE LIC.
I certify that I have read this application and state that the LICENSE NO. CLASS
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,_
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hereby authorize representatives of this County to enter
on the abov entioned property for inspection purposes. SEE REVERSE FOR,EXPLAiVATORY LANGUAGE
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Signature of Applicant or gent Date -