HomeMy Public PortalAbout9502 LAS TUNAS DR_Mechanical__ 4COMPENSATION DECLARATION APPLICATION FOR PERMIT
I hereby affq�4-1i�that I have a certificate of consent to self ,
insure, or^a certificate of Workers' Compensation Insurance, 76A364c HEATING - VENTILATING - AIR CONDITIONING
or a certified />p � (thereof (Sec. 3800, Lab. C.)
CE-818 REV. 10/81)
P❑6licy h7-o. CompanyC.s�tsly�
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 dep rtment. (PRINT OR TYPE ONLY) ADDRESS �, 7(f1,f ff
Date Applicant LOCALITY I �� �/ /•.
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE I ��
CERTIF CATE OF EXEMPT FROM WORKERS' NEAREST
COMPENSATIO INSURANCE CROSS ST. CCsZ-c?Ut��?L
(This section need not be completed if the work involved by ABSORPTION UNIT, BTU DISTRICT NO. PROCESSED BY
AIR HANDLING
the permit is for one hundred dollars ($100)or less.) UNIT, CFM
I certify that in the performance of the work for which this D
permit is issued, I shall not employ any person in any manner BOILERBTU
so as to become subject to the Workers ,Compensation Laws. APPROVALS DATE I PE R'S SIGNATURE
COMPRESSOR, BTU qtypo
0 ROUGH
Date Applicant
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 if 1r)A I N
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU GRAVITY
LICENSED CONTRACTORS DECLARATION �, FLOOR BTU poa
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-5059 3*g Lic. ClassC Z`d, •� Poo-
Contra ctor
Contractor Date �" O
I-
❑ I a /exempt under Sec. LU
Plan check fee
B.BP.C. for this reason H
Date: PERMIT ISSUING FEE $ Z
TOTAL FEE
Signature
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
I hereby affirm that I am exempt from the Contractor's License ,
Law for the following reason (Section 7031.5,. Business and NAME
Professions Code): tQi
❑ I, as owner of the property, or my employees with ADDRESS R4{+T.a
wages as their sole compensation,will do the work and
the structure is not intended or offered for sale Section CITY TEL. NO.
( 3307. . . 52.00
7044, Business and Professions Code).
OWNER
❑ I, as owner of the property, am exclusively contracting
with licensed contractors to construct the project (Sec- MAIL �� � ���� .52
tion 7044, Business and Professions Code). ADDRESS TOTALn.0�y0R1R.J
CONSTRUCTION LENDING AGENCY CITY /`b`�?� TEL. NO. CHECK 52.00
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTOR ` 5�p i�urt L , CHS .OU
(Sec. 3097, Civ. C.). 1. z.
ADDRESS Z SJ. .+.y Auc y L
Lender's Name ��/ 4? �V-Vi l OI15Iug
CITY r TEL. NO.
Lender's Address STATE LIC. 3999 1, AM10i47
1 certify that I have read this application and state that the LICENSE NO. 7 QS9�� CLASS
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
upo :thybove-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
g ature of Applicant or Agent to