HomeMy Public PortalAbout9627 LONGDEN AVE_Mechanical__ TION
WO(im that
I'have a cerci DECLARATION APPLICATION FOR PERMIT
I hefeby a'rfifm that I have a certificate of consent to self ,
insure,cl'r a.certificate of Workers'Compensation Insurance, HEATING - VENTILATING - AIR CONDITIONING
or 3'certified copy thereof(Sec. 3800, Lab. C.) 76A364C
I CE-818(REV. 10/81)
Policy No.-Company
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. (PRINT OR TYPE ONLY) ADDRESS
Date Applicant LOCALITY I
NO. TYPE OF APPLIANCE OR EQUIPMENT FEE NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE CROSS ST.
(This section need not be completed if the work involved by I ABSORPTION UNIT,BTU DISTRICT NO. PROLE e
the permit is for one hundred dollars(;100)or less.) ` /S(
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM (/U
permit is issued, I shall not employ any person in any manner BOILER,BTU
so as to become subject to the Workers'Compensation Laws. APPROVALS DATE I#EC5WS SIGNATURE
�.�y I COMPRESSOR, BTU ROUGH —�
Date" Applica �i
ZV
NOTICE TO APPLICANT: If Per 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 VALIDA:1116_N
with comply with such provisions or this permit shall be
deemed revoked. I FURNACE: FAUGRQVTY
LICENSED CONTRACTORS DECLARATION FLOOR BTU (/(1
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.
O
License Number Lic. Class ► V
Contractor Date
❑ I-am exempt under Sec.
Plan check fee
B.BP.C. for this reason' 'PERMIT ISSUING FEE$
Date: '
Mgv
TOTAL FEE
. Signature i F324I
OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT
Ihereby affirm that I am exempt from the Contractor's License , 4 2 5 9 A
Law for the following reason (Section 7031.5, Business and NAME
Professions Code): # 0 0 0 0 0 8
'
El 1,I, as owner of the property, or my employees with ( Sn J.
wages as their sole compensation,will do the work and r q-(3
3 a 5
the structure is not intended or offered for sale(Section CIN TEL. NO. 0
7044, Business and Professions Code). OWNER = a 0 a 3 Q 5 0
El1, as owner of the property,am exclusively contracting e
with licensed contractors to construct the project (Sec- MAIL gQ ` 0 3 1 9-8 b
tion 7044, Business and Professions Code). ADDRESS
CONSTRUCTION.LENDING AGENCYCITY TEL. NO.
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued CONTRACTOR C
(Sec. 3097, Civ. C.).
ADDRESS ,
Lender's Name
CITY TEL. NO.
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,
and hereby authorize representatives of this County to enter
upon the above-mentioned pro for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Applicant or Agent Date