HomeMy Public PortalAbout10260 LIVE OAK AVE_Mechanical__ Offifm that
COMPENSATION DECLARATION n P P C n 7 M N FOR n E RWT
I•hereby;affl+m that I have a certificate of consent to self (� L� /ri1 ll`rl (�'
rnsure' or a certificate of Workers' Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec 3800, La C 76A364C
_ CE-818(REV 10/81)
Policy No pany
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 AA /
tion epartm nt //J�II//OO��� ���� ,[[1��� (PRINT OR TYPE ONLY) ADDRESS 0"C) � % Qrl f�•
Date A hcont `'�K• -Cia 2ztl Lt�t LOCALITY
pp �� NO TYPE OF APPLIANCE OR EQUIPMENT FEE �-Q-
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST
COMPENSATION INSURANCE CROSS ST (rl!
(This section need not be completed if the work Involved by ABSORPTION UNIT, BTU DISTRICT NO PROCESSED,B.(
the permit is for one hundred dollars ($100)or less.) ;
AIR HANDLING UNIT, CFM r
I certify that In the performarice of the work for which this /
permit Is Issued, I shall not employ any person in any manner BOILERBTU
so'a ,s to become subject to the Workers'Compensation Laws APPROVALS, DATE INSP OR'S SIGNA RE
Date Applicant COMPRESSOR, BTU ROUGH
NOTICE 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 VALIDATI
with comply with such provisions or this permit shall be
deemed revoked FURNACE FAU GRAVITY -
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 Code, and my license is in full force and effect
License Number aLic Class ✓� 3G Lu{ V
- oao � G6 D
Contractor A 42411A447 Date Z
❑ I am exempt under Sec
Plan check fee
w
B&P C for this reason -Date �
PERMIT ISSUING FEE 9 9 2 5 3 A
'
Signature TOTAL FEE 1 # o o'o o ro 8
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's LicenseD '1 o o 20,50
Law for the following reason (Section 7031 5, Business and NAME
Professions Code) o,o o 2 Q 5,Q
❑ 1, as owner of the property, or my employees with ADDRESS
wages,as their sole compensation,will do the work and CITY TEL NO 03.28-88
the structure is not intended or offered for sale(Section
7044, Business and Professions Code)
OWNER - •
❑ j, as owner of the property, am exclusively contracting I
with licensed contractors to construct the project (Sec- MAIL
tion 7044, Business and Professions Code) ADDRESS
CONSTRUCTION LENDING AGENCY CITY ace� TEL NO
I hereby affirm that there is a construction lending agency for D
the performance of the work for which this permit Is issued CONTRACTOR J?,q_ - �G.—
(Sec 3097, Civ C ) ,Wo
ADDRESS
Lender's Name
CITY
Lender's Address
STATE VLIC
L
I certify that I have read this application and state that the LICENSE NO 461;2 iIIIP or 1 CLASS !-� 1�' 3 6
above information is correct I agree to comply with all County
ordinances and State jaws relating to building construction,
and hereby authorize representatives of this County to enter
upon the above-mentioned property for Inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date - -