HomeMy Public PortalAbout9716 LEMON AVE_Mechanical__ V''RKERS'COMPENSATION DECLARATION APPLICATION FOR PERMIT
r+ m that I have a certificate of consent to self ,
t•4 certificate of Workers' Compensation Insurance,
d copy thereof (Sec 3800Lab C `/6A364C HEATING - VENTILATING -`AIR CONDITIONING
or•
CE-818(REV 10/81)
Polic �7 Company' , iii 60 /07C�
❑ 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 7/
tion part ent ADDRESS
Q� /n/ (PRINT OR TYPE ONLY)
Date Applicant a LOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST
(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
I certify that in the performance of the work for which this .,
permit is Issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws BOILER, BTU APPROVALS DATE INSP TOR'S SIGNATURE
Date /applicant COMPRESSOR, BTU�6� ROUGH
NOTICE TO APPLICANT If, after making thisCertificate of VENTILATION SYSTEM FINAL f
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 J G AV Y
LICENSED CONTRACTORS DECLARATION FLOOR BTU 6_s O2S0
I hereby affirm that.l am licensed under provisions of Chapter 9 HEATER SUSPENDED UNIT WALL
' .(commencing with Section 7000) of Division 3 of the Business' �
and Professions Code,and
d
my license is in full force and effect
License NNumber9-74MO 'Lic Class C'�� ►
Contra or�� //C date O
❑ i �
jam exempt under Sec us
Plan check fee H
B 8P C for this reason PERMIT ISSUING FEE $ J0 Z
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) u
❑ j, as owner of the property, or my employees with ADDRESS
wages as their sole compensation,will do the work and ACCT os
the structure Is not intended or offered for sale(Section CITY TEL NO 330.7 _30.50
7044, Business and Professions Code)
❑ I, OWNER- I ITEMS as owner of the property, am exclusively contracting _
with licensed contractors to construct the project (Sec- MAIL
q:z tion 7044, Business and Professions Code) ADDRESS {� TOTAL 30 m ti tics
0
CONSTRUCTION LENDING AGENCY CITY �" TEL NO CHEC•Y�' '�e�Cl
I hereby affirm that there is a construction lending agency forze
the performance of the work for which this permit is issued 'CONTRACTO — �- S �� , CHANGE °00
(Sec 3097, Civ C )
ADDRESS / (I � i
Lender's Name �l! J� - - - - - - -- -- - �Q0'0�I tdt/iJwy
Lender's Address CITY TEL NQ - —f21 ��L i AM 8:48 STATE LIC /� y� 1384 1 A f 'F
j certify that I have read this application and state that the LICENSE NO 2 CLASS
above information is correct I agree to comply with all County
ordinancesAandStlaws relating to building construction,
and herebrepresentatives of this County to enter
n t aoned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date - " '