HomeMy Public PortalAbout10022 LIVE OAK AVE_Mechanical__ DEC
TION
WORKERS' Ihave COMPENSATION cafe of corse APPUCATPON FOR FERMI
I he:,,e�bv,affirm that I have a certificate of consent to self ,
insure,'or n certificate of Workers' Compensation Insurance, 76A364c HEATING - VENTILATING - AIS CONDITIONING
ci certifiescopy thereof (Sec 3800,'Lab 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 /� '
tion department ADDRESS /`
(PRINT OR TYPE ONLY)
Date Applicant 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.), r
I certify that in the performance of the work for which this AIR HANDLING UNIT, CFM t
permit Is Issued, I shall not employ any person In any manner
BOILER, BTU
so as to become subject to thed1,VesC6r ' mDer SOtIOn Laws /) APPROVALS_ DATE SP OR'S SIGNAT RE
Date ppllc `— I COMPRESSOR, BTU OV C1� ROUGH G
NOTICE TO APPLICANT If, after making I certlflcate o VENTILATION SYSTEM FINAL
Exemption, you should become sublect to rhe Workers'
Compensation provisions of the Labor Code, you'must forth- EVAPORATIVE COOLER VALIDATIM
with comply with such provisions or this permit shall be
deemed revoked FURNACE FAU GRAVITY—
LICENSED
RAVITY LICENSED CONTRACTORS DECLARATION ' FLOOR BTU V(i
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED—UNIT—
(commencing
USPENDED UNIT(commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code,and my license Is In full force and effect
0
License Number LIc Class D l7
OC
Contractor Date 0
t—
❑ -I am exempt under Sec LU
Plan check fee
N
B 8P C for this reason PERMIT ISSUING FEE $ S Z
Date
TOTAL FEE
Signature ,
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT ;2 8 2 9 6 A
I hereby affirm that I am exempt from the Contractor's License
Law for-the following reason (Section 7031 5, Business and NAME D # 0 0 0 0.0 8
Professions Code)
❑ I, as owner of the property, or my employees with ADDRESS I o o 3 Q,5 0
wages as their sole compensation,will do the work and
the structure Is not Intended or offered for sale(Section CITY TEL NO 0•o 0 3 Q,5,10 6
7044, Business and Professions Code) OWNER
El1, as owner of the property, am exclusively contracting �� A 05-87
with licensed contractors to construct the project (Sec- MAIL
ADDRESS
tion 7044, Business and Professions Code)
CONSTRUCTION LENDING AGENCY CIT TEL NO
I hereby affirm that there is a construction lending agency for If F
the performance of the work for which this permit Is Issued CONTRACTO - � 4, D
(Sec 3097, Civ C ) I Ill:
ADDRESS / es
Lender's Name
CITY TEL NO
Lender's Address
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 jaws relating to building construction,
an ereby authorize representatives of this Coun to enter
o th aboveveloned operty for insp ctio pur oses, SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date '