HomeMy Public PortalAbout5525 HILTON AVE_Mechanical__ affirm that
COMPENSATION DECLARATION APPLICATION FOR PERMIT
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affirm that hove a certificate of consent to self
a ccopy t e eo Workers' Compensation Insurance, 76A364C HEATING - VENTILATING - AIR CONDITIONING
ied copy thereof (Sec 3800, Lab. C.) CE 818(REV. 10/81)
Policy N 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 SS2 /L�a, (`r
tion department. (PRINT OR TYPE ONLY) ADDRESS ✓ J
Date Applicant LOCALITY T L� e,
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
ri
CERTIFICATE OF EXEMPTION FROM WORKERS' NEARESTn o.N "J J
COMPENSATION INSURANCE CROSS ST. ,C /1 fN '
PROCESSED BY BTU DISTRICT NO. /
(This section need not be completed if the work involved by ABSORPTION UNIT, r
the 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 Sr � eA�
permit is issued, I shall not employ any pers In any manner
so as to become subject to the Workers' peInsation Lows. BOILER, BTU APPROVALS DATE SPT R'S SIGNATURE
COMPRESSOR, BTU 3( aoo, L ROUGH
Date / aApplicant _
NOTICE TO APPLICANT: If, after making this Certif' ate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the orkers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER ALIDATION
with comply with such provisions or this permit shall be �q QQ
deemed revoked FURNACE: FALL
D�)� p Ll
LICENSED CONTRACTORS DECLARATION FLOOR BTU /
I hereby affirm that I am licensed under provisions of Chapter 9HEATER: SUSPENDED UNIT_
.
`(commencing with Section 7000) of Division 3 of the Business WALL r
and Professions Code,and my license is in full force and effect. d
O
License Number Lia Class - ► V
I cc
Contractor Date - 0
❑ I am exempt under Sec. uVi
Plan check fee - N
.8P.C.
8for this reason'
Date: Z
PERMIT ISSUING FEE $
'
Signature TOTAL FEE _0) $3 5 0 4 A
OWNER-BUILDER DECLARATION .PLAN CHECK APPLICANT # o e e e e 8
I hereby affirm that I am exempt from the Contractor's License ,
Law for the following reason (Section 7031.5, Business and NAME
Professions Code):
❑ 1, as owner of the property, or my employees with ADDRESS J e e 3 0,5 0
wages as their sole compensation, will do the work and CITY TELNO. e 3 05 0 xv
the structure is not intended or offered for sole(Section . • e
7044, Business and Professions Code).
owNER '4j) r/ t.l 1,.1 q . 85
❑ 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 sz
- -
CONSTRUCTION LENDING AGENCY CITY -- TEL NOO _
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 C -
Lender's Name J
CITY TEL. NO. -
Lender's Address
STATE LIC. _ ry
certify that I have read this application and store that the LICENSE NO. 35 CLAS it -
above information is correct. I agree to comply with all County
ordinances and State laws relating to building construction,
and h r y authorize representatives of this County ro enter
u a bove-mentioned property far inspe ion SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant r Agent Dote