HomeMy Public PortalAbout6408 LIVIA AVE_Mechanical__ �r} WORKERS'COMPENSATION DECLARATION n P(�(( CAYMN FOR f�jERM7
I hereby affirm that I have a certificate of consent to self 6�d Ir IS Il Cl FOR I�LSu�1
nssure, or a certificate of Workers' Compensation Insurance, 76A364CHEATING = VENTILATING - AIR CONDITIONING
or a certified copy thereof (Sec 3800, Lab C ) r
/ p�/ CE-818(REV 10/81) -
Policy No inn �/8, Company .5/A-/:e �- ymd
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 r
tion depart en ADDRESS �J.4 �� 1 fid / 14 �`0
C), 1� (PRINT OR TYPE ONLY)
Date Applicant ��! �' n LOCALITY T
NO TYPE OF APPLIANCE OR EQUIPMENT FEE ! `
CERTIFICATE OF EXEMPTION FROM WORKERS' /
COMPENSATION INSURANCE CROSS ST EC)1Q*/�t�1� r lfv�a L �'
(This section ne not be completed If the ork Involved by ABSORPTION UNIT, BTU DISTRICT NO pp��� PR ESS BY
the permit is for o e hundred dollar 00)or less.) AIR HANDLING UNIT,CFM (l
1 certify that m the p ormanee of the work for which this S
permit is Issued, I shall n �ployrson in any manner
BOILER, BTUsom to become shall toompensation Laws nPPaovn s DATE N EcroR's SIGN aeCOMPRESSOR, BTU `t 00 y ROUGH
Date Appicnr
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 FURNACE FAU GRAVITY _
LICENSED CONTRACTORS DECLARATION FLOOR . BTU
I hereby affirm that I am licensed under provisions of Chapter 9 HEATER SUSPENDED UNIT ' 011
-(commencing with Section 7000) of Division 3 of the Business CJ
and Professions Code,and my license is in full force and effect
_ a
0
License Number J Li Class L' Q D V
f-1/`/i_c. a 0- At/j OG
Contractor l JO`trJ � Date X01 g-e O
r-,
❑ I am exempt under Sec d
Plan check fee
B&P C far this reason N
/7- for-{/ PERMIT ISSUING FEES Ls L9 08 9.-8 A
Signature�2 r� l:!! 1//�'i TOTAL FEE
OWNER-BUILDER DECLA N PN CHECK APPLICANT # o o to e o 8
ANIOA
I hereby affirm that I am exempt from the Contractor's License - D 1 ° ° 30.50
Law for the folly Ing reason (Section 7031 5, Business and NAME
Professions-Code) /
El 1, ° ° e 3 0 5 0 x
I, as owner of the property, or my employees with
wages as their sol\ compensation, w�4clo the work and
the structure is not Intended or offered for sale(Section
CITY TEL NO I A 2t-88
la
7044, Business and Professions ode) - - �'/ ) / J �! /� ) ) '
❑ ` � OWNER �//gJ N� Y L 1-�/ J7 Jy 9� L L t�
I, as owner of the property, m exclusively contracting
with licensed contractors o construct the project Sec-
hon 7044, Business an 'Professions Code)p l ( ADDRESS �!� q (��! z7 A✓�
CONSTRUCTI LENDING`AGENCY CITY,,-7-- n � �` TEL NO�*7_-��, -7
1 he,reby affirm that thf is a constructed lending agency for Y D
the performance of e work for which t is permit is Issued 'CONTRACTOR 14 4-jel' `�Q/9 /jd �L fflO�t'/L-
(Sec 3097, Civ C� � /�
Lender's Name, ADDRESS
CITY (��GSI/ �L TEL NO
Lender's Address '
ATE LIC
I certify that I have read this application and state that the S ENSE NO- �� C ASS rrC V - -•
above information is correct I agree to comply with all County
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County-to enter
upon
the alio e-mint ed property for nspec�tt n purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Si nature of Applicant or t Date - '