HomeMy Public PortalAbout9509-9513 LONGDEN AVE_Mechanical__ WORKERS'Cd�APENSATIOK'DECLARATION APPLICATION FOR PERMIT
t. I hereby,affirtn that I have a certificate of consent to self
` ins6re, or a certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or a certified copy thereo cgec. 3800, Lab. C.) 76A364C
��cis/_j P P y CE-818(REV. 10/81)
Policy No om an COUNTY 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 5 �,oN9dd� I, M 1C�ii
tion department. (PRINT OR TYPE ONLY) ADDRESS J
Date Applicant LOCALITY qi
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE
NEAREST
COMPENSATION INSURANCE CROSS ST.
(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($100)or less.) AIR HANDLING UNIT,CFM - t X
I certify that in the performance of the work for which this L✓ fJ
permit is issued, I shall not employ any person in any manner BOILER, BTU
so as to become subject to the Workers'Compensation Laws. -y_� /n► APPROVALS DATE INSP S SIGNATURE
Date Applicant COMPRESSOR,BTU ��000 Pl� �/ d D ® ROUGH 2
NOTICE TO APPLICANT: If, after making this ertificate of VENTILATION SYSTEM FINAL
Exemption,'you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALIDATI N
with comply with such provisions or this permit shall be
deemed revoked. FURNACE: FAU�_�R Ad[IIIY �j 0�
LICENSED CONTRACTORS DECLARATION FLOOR BTU;'. 4 boy - : d.
I hereby affirm that I am licensed under provision's of Chapter 9 HEATER: SUSPENDED UNIT
'(commencing with Section 7000)of Division 3 of the Business - WALL
and Professions Code,and my license is in full force and effect.
[J l
License Number ��7 9 �J Lic. Clas
s 0
/ •�•�
Contractor Date 2—1 74S
N ❑ I am exempt under Sec.
Plan check fee
B.BP.C. for this reason' /'
PERMIT ISSUING FEE$ V
Date: ''11 3 6 6.9 A
Signature TOTAL FEE V # 0 0 0 0 a 8
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT I o 0 50.50
I hereby affirm that I am exempt from the Contractor's License ►
Law for the following reason (Section 7031.5, Business and NAME 0 0 0 5 Q 5 0 C5
Professions Code): .-
❑ I, as owner of the'property, or my employees with ADDRESS
Ic, 17-85
wages as their sole compensation,will do the work and CITY TEL. NO.
the structure is not intended or offered for sale(Section
7044, Business and Professions Code). / ��
OWNER /C
El 1, as owner of the property,am exclusively contracting �1 d
eW
with licensed contractors to construct the project (Sec- MAIL
ADDRESS �–(/ . �37a
tion 7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CITY ,+ TEL. NO.
I hereby affirm that there is a construction lending agency for ��til /EG/ �8
the performance of the work for which this permit is issued CONTRACTOR — r ,
(Sec. 3097, Civ. C.). .
ADDRESS 3. IJu
Lender's Name '
CITY T-A., TEL. NO..,.I
Lender's Address STATEr1 `C�, p
I certify that I have read this application and state that the LICENSE NO. p� 7 7 P p Q 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
upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
T„ �
Signature of Applicant or Agent Date