HomeMy Public PortalAbout9507 LONGDEN AVE_Mechanical__ - Nrm that
COMPENSATION DECLARATION APPLICATION FOR PERMIT
� I••hereby affiffirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereof ec. 3800, Lab. C.) 76A364C
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y7� CE-818(REV. 10/81)
Policy No.5962,3/ ompany COGNTY OF LOS ANGELES BUILDING AND SAFETY
Certified copy is hereby furnished.
Certified copy is filed with the county building inspec- FOR APPLICANT TO FILL IN BUILDING
tion department. ADDRESS 95
(PRINT OR TYPE ONLY)
Date Applicant LOCALITY L
CERTIFICATE OF EXEMPTION FROM WORKERS'
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREST r/
COMPENSATION INSURANCE CROSS ST.
(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
I certify that in the performance of the work for which this
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. BOILER, BTU J �J APPROVALS DATE INS ORS SIGNATURE
Date- Applicant � Tl[/!�i COMPRESSOR, BTU Y-9 '•� (/ od ROUGH
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL 29% 3 i
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 10iri&IA 112` :P a�
I hereby affirm that I am licensed under provisions of Chapter 9SUSPENDED UNIT
(commencing with Section 7000)of Division 3 of the Business HEATER: WALL
and Professions Code,and my license is in full force and effect. o �'
Y
Q �1 �
License Number ` "O Lic. Class � y ► u
Contractor Date /'d pOp-..
❑ I am exempt under Sec. LU
Plan check fee N
B.&P.C. for this reason Date. PERMIT ISSUING FEE$ WD G
4,, 67,OA
TOTAL FEE
Signature 5
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT # 0 0 o a 0 8
1 hereby affirm that I am exempt from the Contractor's License , 10 o 3 0,50
Law for the following reason (Section 7031.5, Business and NAME
Professions Code): o 0 0 3 0,5 0�_,,
❑ I, as owner of the property, or my employee%with ADDRESS
wages as their sole compensation,will do the work and 1 21 7-85
the structure is not intended or offered for sale(Section CITY TEL. NO.
7044, Business and Professions Code). ^
OWNER �PrCLI� LJ66E�
❑ I, as owner of the property, am exclusively contracting MAIL
with licensed contractors to construct the project (Sec- ADDRESS r• - 37
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY —r4�Pea (A2 _TEL. NO. 02$ -Z$f 8
I hereby affirm that there is a construction lending agency for ,
the performance of the work for which this permit is issued CONTRACTOR
£ O E
(Sec. 3097, Civ. C.). EA
Lender's Name ADDRESS E59 37 �0 A k AVJ E W LL13
Lender's Address CITY TEL. NO.2OJ —124 8
STATE •LIC, D
1 certify that I have read this application and state that the LICENSE NO. I) 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
Un.the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Un
Signature of Applicant or Agent Date