HomeMy Public PortalAbout5475 HILTON AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION / / f �) /3/ S'
hereF ,.ffum that I have a certificate of consent to self APPLICATION FOR PERMIT l� /
insure r a ceryficate of Workers' Compensation Insurance, 76A364C HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec. 3800, Lob. C.)
CE-818(REV. 10/81)
Policy No. Company
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
❑ Certified copy is filed with the county building inspec- - FOR APPLICANT TO FILL IN BUILDING y��
tion department. (PRINT OR TYPE ONLY) ADDRESS
Date Applicant LOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST ,
COMPENSATION INSURANCE CROSSST.
ABSORPTION UNIT, BTU DISTRICT NO. caOCESSED Br
(This section need not be completed if the work involved by �//
the permit is for one hundred dollars ($100)or less.) AIR HANDLING UNIT, CFM �A
I certify that in the performance of the work for which this L VVV
permit is issued, I shall not employ any person in any manner
so asto become subject to the Workers'COmpensatia laws. BOILER, BTU APPROVALS DATE INSPE R'S SIGNATURE
DajP7�ecpp l icon s COMPRESSOR. BTU 14 10 0 0 / ROUGH
116TICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers' -
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or'this permit shall be
deemed revoked. - FURNACE: FAU GRIVVITY J
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9HEATER' SUSPENDED UNIT_WALL
'(commencing with Section 7000) of Division 3 of the Business }
and Professions Code, and mylicense is in full force and effect. d
zy
License Numbe, ?14 /lic. Class0o,7_0 , V
<_� G 49
Contractor �/' e - O
H
❑ I am exempt under Sec. 2 0 3 0 P W
Plan check feed
B.BP.C. for this reason # C e,e e e Z
Date:
PERMIT ISSUING FEE $ (7
Signature
TOTAL FEE v ( e . 3 4 5 0
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 7 2 8e a f}
Professions Code): 0
❑ I, as owner of the property, or my employees with ADDRESS
wages as their sole compensation, will do the work and CITY TEL. NO.
the structure is not intended or offered for sale (Section
7044, Business and Professions Code). +
OWNER
E] O
I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL
IAtV
tion 7044, Business and Professions Code). ADDRESS l l ��
CONSTRUCTION LENDING AGENCY ' 'CITY_- G L. NO�rg6
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.).
ADDRESS
Lender's Name
CITY 'RwIYefEe
Lender's Address �Wl -
STATEs
r
I certify that I have read this application and state that the LICENSE NO. CLASS - Q -
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction, _
and hereby authorize rep sentatives of this County to enter -
upon above-me 'r� d property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Dote -