HomeMy Public PortalAbout5936 IVAR AVE_Mechanical__ WORKERS'COMPENSATION DECLARATION
AL•kerebyi.effirm that I have a certificate of consent to self rxP APPLICATION FOR PERMIT
iwL,,e, or acertificate of Workers'Compensation Insurance, 76A364C "j U.� HEATING - VENTILATING AIR CONDITIONING
or a certified copy thereof (Sec. 3800, Lab. C.)
CE-818(REV. 10/81)
Policy No.fiZoc ®pEt'�Company � � b
Certified copy is hereby furnished. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is filed with the c unty blvilding inspec- FOR APPLICANT TO FILL IN BUILDING
tion lepartment. (PRINT OR TYPE ONLY) ADDRESS ✓
Date—50/w Applicant LOCALITY
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST.
ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY
(This section need not be completed if the work involved by
the permit is for one hundred dollars ($100)or less.)
1 certify that in the performance of the work for which this AIR HANDLING UNIT, CFM
permit is issued, I shall not employ any person in any manner BOILER, BTU
so as to become subject to the Workers Compensation Laws. APPROVALS DATE INSCTOR'S SIGNA;V7E.
it
Date Applicant COMPRESSOR, BTU V F✓� ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should become subject to the Workers' i
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATI N
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GR VITY ® O�
LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER: SUSPENDED UNIT
(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Cod and my license is in full force and effect. — µ,n r.fQ 7�
r � ''�� 1 c C., JP51 V
License Number Z� Lic. Classss_� , U—
U• � v J 0-
Contractor Date
❑ o U
I am exempt under Sec. LU
Plan check fee
B.&P.C. for this reason
PERMIT ISSUING-FEE $ .0 sa
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
Professions Code):
❑ I, as owner of the property, or my employees with ADDRESS _t'
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 111111 — -
the performance of the work for which this permit is issued CONTRACTOR J/kt1 l*l�TAiL 6/4�r a-
(Sec. 3097, Civ. C.').
ADDRESS
Lender's Name / Jam— 9 (�
CITY Q l?G TEL. NO. / 3 ry _7 I •f.t-• r
Lender's Address f i . .
STATE ��Z 2/' UC.
I certify that I have read this application and state that the LICENSE NO. / b CLASS C�"�
above information is correct. I agree to comply with all County
ordinances and St to laws relating to building construction,
and h by th r ze representatives of this County to enter
upon ob d property for insp ction purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
S o
Signature of Applicant or Agent Date