HomeMy Public PortalAbout6453 LIVIA AVE_Mechanical__ ' W+ ORKERS' COMPENSATION cafe of N t '� APPn OCA7MN FOR PERWT
insureboisa certrf cffirm ute of Workers' Compensation on consent
nsurance, LL J
or a c rtified c �' thereof (Sec 3800, Lab C ) 76A364C HEATING -- VENTILATING - AIR CONDITIONING
F 4.r_ • �- 111 'CE-818(REV 10/81)
Policy No Company
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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 t
y J
(PRINT OR TYPE ONLY), J1 ✓
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Date Applicant LOCALITY
c�
_ NO TYPE OF APPLIANCE OR EQUIPMENT - FEE •h^-
CERTIFICATE OF EXEMPTION FROM WORKERS' NEAREST ,r
COMPENSATION INSURANCE CROSS ST
(This section need not be completed if the work Involved by ABSORPTION UNIT, BTU DISTRICT-NO PR SSED Y
the permit is For one hundred dollars($100)or less.)
I certify that in the performance'of the work for which this AIR HANDLING UNIT, CFM D (}
r permit is Issued, I shall not employ an soh in any manner BOILER, BTU o
so as to become subject to the - .ers" ompensation La APPROVALS DATE INSPECTORS SIGNATURE
Q —��•
Date licant, COMPRESSOR, BTU ROUGH
� App
NOTICE TO APPLICANT If, of aking this Certificate of VENTILATION SYSTEM FINAL
Exemption, you should' b o e subject to the Workers'
Compensation provisions of t Labor Code, you must forth- EVAPORATIVE COOLER VALIDATION
with comply with such provisions or-this permit shall be
deemed revoked I . I FURNACE FAU GRAVITY
LICENSED,CONTRACTORS,DECLARATION. FLOOR l BTU— D
I hereby affirm that I am licensed under provisions of Chapter 9. HEATER SUSPENDI-D ' UNIT
(commencing with Section 7000) of Division 3 of The Business WALL
and Professions Code,and my license is injull force and effect
12F 0d
License Number Lic Class D V
Contractor Date 0
E] I-
LU am exempt under Sec W
Plan check fee d
B &P C for this reason H
Date
PERMIT ISSUING FEES Z
_ - `
Signature - TOTAL FEE
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License D
Law for the following reason (Section'7031 5, Business and NAME
Professions Code)
❑ I,'.as owner of the property, or my employees with ADDRESS /
wages as their sole compensation,will do the work and TEL NO
CITY ��+� v
the structure is not Intended or offered for sale(Section
7044, Business and Professions Code)
.�� AOWNER. .-,J
I, as owner of the property, am exclusively contracting `
with licensed contractors to construct the project (Sec- MIL
tion 7044, Business and Professions Code) ADDRESS vl t 't7t/L' 571. A }
CONSTRUCTION LENDING AGENCY CITY �• TEL NO ��
I hereby affirm that there is a construction lending agency for 0 0 o e o 8 .
the performance of the work for which this permit Is issued CONTRACTOR D ( 0 - 58,5 0
(Sec 3097, Civ C )
ADDRESS 'f 0 �.P.5 8.5 0 5_
Lender's Name '
CITY TEL NO ( Q 2 x 8 6
- '
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 laws relating to building construction,
7thr
horize represe tives of this County to enterbov -menti erty for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE -
I ature of App Ican r Agent Date
it .