HomeMy Public PortalAbout9821 LIVE OAK AVE_Mechanical__ ORKERS'COMPENSATION DECLARAV
Ihereby affirm that I ha-e'a cerpficate of co"- .I If APPUC ATTO 1 FOR PE6°MT
insure, or a certificate of Workers' Compensation Insu once,
or a certified copy thereof (Sec' 3800, Lab C ) 76A364C BEATING - VENTILATING - AIR CONDITIONING
CE-818(REV 10/81)
Policy No' mp6y
Certified copy is hereby furnished COUNTY OF LOS ANGELES BUILDING AND SAFETY
FM Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING /}/
t��,,pjjct
ADDRESS vS
(PRINT OR TYPE ONLY)Date LOCALITY
NO TYPE OF APPLIANCE OR EQUIPMENT FEE
CERTIFICATE OF EXEMPTI FROM WO RS' NEAREST
COMPENSATION INSURANCE t CROSS ST r
(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 v
permit is issued, I shall not employ any person in any manner BOILER, BTU
so as t0 become subject to the Workers'Compensation Laws _ APPROVALS DATE INSPECT R'S NATURE
Date ApplicaritCOMPRESSOR, BTU C) 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 N
with comply with such provisions or this permit shall be
deemed revoked i FURNAC FAU VITY /
LICENSED CONTRACTORS DECLARATION F I
I hereby affirm that i am licensed under provisions of Chapter 9 HEATER SU ENDED UNIT
\ (commencing with Section 7000) of Division 3 of the Business WALL
and Professions Code,and my license is in full force and effect d
� O
Lic se Number S Lic Class 0 --2-0 D V
on ctor � � Date 1 - 21 8 0 9 A o
i V
I am exempt under Sec 0 0 0 0 0 8 U
Plan check fee H
B 8P C for this reason PERMIT ISSUING FEE $ 1 - 3050 z
Date ��
Signature TOTAL FEE _�q SV 00030,505)
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT o4, 05-85
1 hereby affirm that I am exempt from the Contractor's License1.
D
Law for the'following reason (Section 7031'5, Business and NAME
Professions Code)
❑ 1, as owner of the property, or my employees with ADDRESS \
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 MAIL
with licensed contractors to construct the,project (Sec- ADDRESS
tion 7044, Business and Professions Code)
'CONSTRUCTION LENDING AGENCY CITY TEL NO
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
Lender's Name
Lender's Address CITY
NO
/���[ IFI
STATE �/�- LIC � T
I certify that I have read this application and state that the LICENSE NO CLASS — l�
above information is correct I agree to comply with all County
ordinances and State jaws relating to building construction,
er y authorize representatives of this County to enter -
p mentioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
ignature of A li nt or Agent Date .-